Columbia  ^anibers^itpCowx.  I 
^n  tfte  Citp  of  Jgelti  gorfe 

College  of  ^fjpgicians  anb  ^urgconjf 


l^efercnce  Urtirarp 


DISPENSARIES 

THEIR  MANAGEMENT  AND 
DEVELOPMENT 

A  Book  for  Administrators,  Public  Health  Workers,   and 

All  Interested  in  Better  Medical  Service 

for  the  People 


By 

MICHAEL  M.  DAVIS,  Jr.,  Ph.D. 

Director  of  the  Boston  Dispensary 

and 

ANDREW  R.  WARNER,  M.D. 

Superintendent  of  Lakeside  Hospital^  Cleveland 


THE  MACMILLAN  COMPANY 
1918 

All  rights  reserved 


Copyright,  1918 

By  the  MACMILLAN  COMPANY 

Set  up  and  printed.    Published  September,  1918 


1\  ii'^C 

_J)  it) 


TABLE  OF  CONTENTS 

Page 
Preface v 

SeCTTION   I:   HiSTOEICAL 

Chapter  I  How  Dispensaries  Began 1 

II  The  PubHc  Health  Motive  and  the  Eflaciency 

Idea 11 

III  Present  Scope  and  Extent  of  Dispensaries  in 

the  United  States 25 

Section  II:  Fundament.'^  Principles 

Chapter  IV          Who  are  Dispensary  Patients? 42 

V  Vilio  Should  be  Dispensary  Patients? 59 

VI  The  Ten  Essentials  of  a  Chnic 71 

VII  Medical  and  Administrative  Organization ....  81 

VIII  Social  Service 101 

Section  III:  Technique 

Chapter  IX         Dispensary  Buildings 121 

X  Dispensary  CHnics:  Equipment;  Organization; 

Education  and  Preventive  Medicine 141 

XI  Dispensary  Clinics  continued:  Specialties  and 

Treatment  Clinics;  Laboratory;  X-Ray  De- 
partment ;  Pharmacy 166 

XII  The  Management  of  an  Admission  System  . . .  192 

XIII  Records  and  Statistics 210 

XIV  Follow-up  Systems 233 

XV  Efficiency  Tests 248 

XVI  Finance 262 

Section  IV:  Specl^l  Types 

Chapter  XVII     The   Out-Patient   Department   of   the   Small 

Hospital 282 

XVIII  The  Pubhc  Health  Dispensary  and  the  Health 

Center 297 

XIX  The  Specialty  Center  and  the  Pay  Clinic. ...     325 

ill 


A-- 


iv  CONTENTS 

Section  V:  Public  Pboblems  Page 

Chapter  XX       Dispensaries  and  the  Medical  Profession ....  345 

XXI  The  Efficient  Dispensary  of  the  Future 360 

XXII  Financing  Better  Medical  Service 372 

XXIII  The  Organization  of  Dispensary  Service  for  a 

Community 382 

XXIV  Conclusion 400 

BiBLIOGBAPHT 406 

Suggestions  for  By-laws  and  Rules  of  a  Dispensary 415 

The  Massachusetts  Dispensary  Law 427 

Index 429 


PREFACE 

That  fully  four  million  persons,  or  one  in  every 
twenty-five  of  the  population  of  the  United  States, 
are  annually  receiving  medical  treatment  at  Dispen- 
saries, is  a  fact  of  sufficient  significance  to  raise  the 
question  why  so  little  attention  has  been  given  to 
these  growing  institutions. 

The  name  ^ 'Dispensary,*^  to  which  these  insti- 
tutions are  historically  heirs,  suggests  merely  the 
giving  of  medicine.  This  has  perhaps  delayed  the 
public  mind  in  grasping  the  fact  that  giving  medicine 
has  become  an  incidental  activity,  and  that  the  chief 
present  function  of  Dispensaries  is  furnishing  medical 
advice  and  treatment. 

The  present  generation  has  indeed  witnessed  re- 
markable changes  in  medical  science.  There  have 
come  new  knowledge  of  the  causes  of  disease  and  con- 
sequent progress  in  ability  to  prevent  as  well  as  cure 
it;  a  wonderful  advance  in  remedial  and  reconstruc- 
tive surgery  to  which  the  present  War  is  giving  dra- 
matic witness;  a  growth  of  specialization  in  medicine 
to  a  point  previously  unknown;  and  a  development 
of  new  standards,  new  institutions  for  medical  educa- 
tion, and  of  great  foundations  for  medical  research. 

Are  we  not  perhaps  on  the  threshold  of  advances  in 
medical  service  which  should  follow  the  progress  of 
medical  science?  Is  it  not  the  call  of  democracy  to 
place  the  new  resources  for  health,  the  new  powers  to 
heal  and  to  prevent  disease,  within  the  reach  of  all 
persons,  all  classes  of  society?  It  is  part  of  the  pur- 
pose of  this  book  to  trace  how  the  Dispensary,  as  one 


vi  PREFACE 

type  of  institution  providing  medical  service,  has 
grown  in  numbers,  effectiveness  and  breadth  of  func- 
tion, and  how  large  a  part  it  can  and  should  play  in  an 
inclusive,  democratic  and  efficient  medical  service  in 
the  future. 

More  fully,  the  purpose  of  this  book  may  be  de- 
scribed as  threefold. 

First,  it  aims  to  depict  briefly  the  history  and  pres- 
ent extent  of  Dispensaries  in  the  United  States. 
Except  in  a  very  slight  way,  no  space  is  devoted  to 
developments  in  other  countries. 

Second,  it  aims  to  be  a  handbook  of  the  equipment, 
organization  and  daily  conduct  of  Dispensaries,  so  as 
to  be  of  practical  service  to  their  superintendents, 
trustees,  physicians,  nurses  and  social  workers.  With 
this  in  view,  some  chapters  go  into  the  practical  de- 
tails which  people  who  are  working  in  Dispensaries 
particularly  need  to  know.  The  often  neglected 
problems  of  the  small  Dispensary  have  received  atten- 
tion, as  well  as  those  of  the  larger  institutions.  Sec- 
tion III  (pp.  121-281)  is  mostly  of  this  technical  nature, 
and  may  be  omitted  by  the  general  reader. 

In  the  third  place,  the  book  aims  to  present  the 
Dispensary  as  a  form  of  organization  for  rendering 
efficient  medical  service  to  the  people.  The  Dis- 
pensary has  generally  been  regarded  as  a  form  of 
charity.  To  a  large  extent  existing  Dispensaries  are 
that;  and  worthily  so.  But  the  trend  of  medical 
science,  and  the  necessary  implications  which  follow 
for  medical  service,  create  a  demand  for  the  practice 
of  medicine  through  an  organized  rather  than  through 


PREFACE  vii 

an  individualistic  system  such  as  has  prevailed  in  the 
past.  The  Dispensary  represents  an  organized  sys- 
tem for  the  practice  of  medicine  in  the  treatment  of 
patients  who  are  able  to  go  to  see  the  doctor,  just  as 
the  modern  hospital  represents  the  organized  practice 
of  medicine  for  patients  who  are  sick  enough  to  be  in 
bed.  As  an  institution  for  rendering  efficient  medical 
service  to  ambulatory  patients,  the  future  Dispensary 
must  be  so  organized  as  to  help  the  patient  without 
regard  to  social  class,  and  benefit  the  medical  profes- 
sion by  rendering  the  economic  position  of  the  average 
physician  more  stable  and  his  opportunities  for  pro- 
fessional advancement  larger  and  more  accessible. 
Dispensaries  have  generally  depended  upon  volunteer 
service  by  physicians,  but  this  system,  with  the 
greatly  increased  number  of  Dispensaries,  begins  to 
break  down  of  its  own  weight.  Adequate  service  for 
patients  is  essential  and  to  achieve  this  there  must  be 
proper  remuneration  for  physicians,  such  as  rarely 
obtains  in  Dispensaries  at  present.  The  need  for 
better  ser\'ice  to  all  the  people  in  curing  and  preventing 
disease  is  one  of  the  most  justified  and  insistent  de- 
mands of  today,  and  it  is  our  aim  to  point  out  how 
the  Dispensary  should  and  will  play  a  large  part  in 
answering  this  demand. 

The  War  is  bringing  great  disturbing  and  yet  re- 
constituting forces  to  bear  upon  medicine.  Thou- 
sands of  physicians  are  becoming  accustomed  to  work 
in  an  organization  instead  of  as  individuals ;  hundreds 
are  being  trained  in  specialties  of  surgery,  orthopedics, 
opthalmology,  and  syphilology;  new  lines  of  medical 


viii  PREFACE 

research  are  being  instituted  and  there  will  be  new 
areas  for  the  practical  application  of  the  results  of 
research.  Several  million  soldiers  will  receive  sys- 
tematic and  adequate  medical  service  and  learn  some- 
thing of  its  worth.  The  general  public,  and  in  par- 
ticular the  employers,  will  understand  as  never  before 
the  economic  value  of  health  as  an  element  in  the 
productive  efficiency  of  a  people.  We  may  hope  that 
as  a  result  greater  power  will  be  given  to  preventive 
and  curative  medicine  than  at  any  previous  period. 
We  may  expect  that  when  soldiers  and  doctors  return 
to  civilian  life  after  the  War,  many  substantial  recon- 
structions of  medical  service  will  take  place.  We  may  be 
sure  that  these  changes  will  be  in  the  direction  of  medical 
organization  rather  than  of  medical  individualism.  The 
Dispensary  is  the  medical  organization  which  must 
cover  the  major  portion  of  the  field  in  caring  for  dis- 
ease, standing  between  the  Hospital  on  the  one  hand 
which  provides  for  the  relatively  small  proportion  of 
acutely  incapacitated  patients,  and  the  Public  Health 
Department  on  the  other  hand  which  deals  usually  with 
preventive  work  alone. 

We"  believe  that  the  conditions  arising  out  of  the 
War,  as  well  as  the  rapid  growth  of  Dispensaries 
during  the  years  which  just  preceded,  render  this  book 
timely,  and  we  hope  that  it  will  be  of  service. 

Mr.  Edward  F.  Stevens  has  generously  aided  in 
designing  and  drawing  the  plans  of  dispensary  build- 
ings in  Chapter  IX.  A  considerable  portion  of  the 
manuscript  was  kindly  read  and  helpfully  criticised 
by  Dr.'S.  S.  Goldwater.     To  both  of  these  friends  and 


PREFACE  ix 

to  many  other  physicians,  hospital  superintendents 
and  social  workers,  the  authors  are  under  a  large 
obligation.  To  the  Committee  on  Out-Patient  Work 
of  the  American  Hospital  Association,  of  which  the 
authors  have  been  members,  thanks  are  due  for  con- 
structive thought  and  assistance  on  the  problems  of 
the  Dispensary.  We  feel,  also,  a  debt  of  gratitude  to 
the  Trustees  of  the  Boston  Dispensary,  who,  with  un- 
usual foresight,  have  made  their  institution  in  a  meas- 
ure an  experiment  station  in  methods  of  dispensary 
administration  and  have  thus  enabled  many  problems 
to  be  solved  by  working  them  out  in  practice,  which 
might  otherwise  have  remained  much  longer  within 
the  field  of  theory. 

M.  M.  D.,  Jr. 

A.  R.  W. 


DISPENSARIES :  THEIR  MANAGE- 
MENT  AND  DEVELOPMENT 

CHAPTER  I 
HOW    DISPENSARIES    BEGAN 

In  1665,  the  great  conflagration  which  devastated 
London  brought  in  its  fiery  train  a  blessing,  for  it 
rid  the  city  of  plague.  But  the  germs  of  poverty 
cannot  be  burned  up,  and  the  sickness  and  misery 
that  follow  poverty  were  so  apparent  to  the  public- 
spirited  members  of  the  medical  profession  of  London, 
that  in  1687,  they  voted  that  all  members  of  the  Col- 
lege of  Physicians,  their  professional  organization, 
should  give  their  services  to  the  poor  without  charge. 
In  due  form  they  transmitted  this  resolution  to  the 
Lord  Mayor  and  Alderman.  When,  however,  the 
charitable-minded  sought  to  call  the  good  physicians 
to  the  service  of  the  poor,  no  means  was  found  of 
providing  the  medicines  which  the  doctors  wished  to 
prescribe.  The  pharmacists  of  London  were  at  that 
time  organized  as  a  guild,  the  so-called  Apothecaries' 
Hall;  and  Apothecaries'  Hall  would  not  lower  its 
prices,  even  when  the  College  of  Physicians  requested 
it  on  behalf  of  the  poor. 

The  physicians  did  not  sit  idle  under  this  monopoly 


2  DISPENSARIES 

in  the  prescription  market.  Fifty-three  leading  spirits 
signed  an  agreement  on  December  22,  1696,  to  pay 
ten  pounds  apiece  to  Dr.  Thomas  Burwell,  one  of 
their  number,  which  sum  Dr.  Burwell  was  to  use  for 
medicines  for  the  poor.  Thereupon  the  first  Dis- 
pensary in  the  English-speaking  world  was  opened  in 
the  building  of  the  College  of  Physicians. 

The  First  Dispensary  in  England 

During  the  first  five  years  of  its  existence,  we  do 
not  know  how  many  patients  the  doctors  treated,  but 
it  is  recorded  that  20,000  prescriptions  were  given 
out.  The  physicians,  however,  complained  that  the 
dole  of  medicines  was  more  highly  regarded  by  the 
pubhc  than  the  freely  given  services  of  the  physicians. 
We  do  not  find  this  first  Dispensary  mentioned  in 
Addison's  Spectator;  but  if  the  sentiment  of  the 
educated  London  pubhc  could  have  been  gauged,  we 
should  probably  find  that  the  Dispensary  was  regarded 
as  a  medical  soup-kitchen.  Medicines  and  medical 
service  alike  were  doubtless  thought  of  as  a  dole  to 
the  needy. 

In  the  seventeenth  century  specialists  in  medicine 
had  not  appeared;  modern  scientific  aids  to  diag- 
nosis were  unknown,  treatment  was  necessarily  of 
symptoms  of  diseases  rather  than  of  causes.  The 
giving  of  medicines  played  a  larger  part  in  theory 
and  in  practice  than  it  does  today.  The  spirit  of 
service  characteristic  of  the  medical  profession,  which 
led  the  London  doctors  of  1696  to  establish  the  first 
Dispensary  in  the  English-speaking  world,  is  the  one 


HISTORICAL  3 

fine  continuing  element  through  the  whole  history 
of  the  dispensary  movement  from  this  early  begin- 
ning. 

The  later  history  of  this  first  London  Dispensary 
is  obscure;  not  until  the  latter  part  of  the  eighteenth 
century  are  Dispensaries  again  noticeable  in  London.^ 
In  1770  the  so-called  ^^ General  Dispensary^'  was 
started  and  four  years  afterward,  the  ^'Westminster 
Dispensary^';  in  1779  the  ^'London  Dispensary/'  in 
1780  the  'flushing  Dispensary"  and  in  1782  the  ''East- 
ern Dispensary,"  These  institutions  were  supported 
mainly  by  private  subscriptions,  usually  of  one 
guinea;  patients  were  only  accepted  when  recom- 
mended by  a  subscriber  and  it  is  said  that  they  were 
required,  when  discharged  from  the  care  of  the  Dis- 
pensary, to  return  thanks  to  the  subscriber  by  letter. 
Dr.  Lettsom,  one  of  the  first  physicians  of  the  General 
Dispensary  in  London,  said,  under  date  of  1801, 
referring  to  the  five  London  Dispensaries,  "50,000 
poor  persons  are  relieved  annually,  one  third  of  whom 
are  attended  at  their  own  dwelHngs:  a  mode  of  relief 
which  keeps  the  branches  of  the  family  from  being 
separated  and  affords  the  wife  an  opportunity  of 
nursing  the  sick  husband,  or  child,  or  the  husband 
to  superintend  and  protect  the  sick  wife.  And  by 
this  mode  of  conveying  rehef  to  the  bosoms  and 
houses  of  the  poor,  the  expense  is  trivial  indeed,  as 
one  guinea  which  is  the  annual  subscription  of  a 
governor,  affords  the  means  of  relief  to  at  least  ten 
patients. " 

Thus  during  the  latter  part  of  the  eighteenth  can- 


4  DISPENSARIES 

tury  Dispensaries  blossomed  in  the  English  metrop- 
oHs.* 

Dispensaries  do  not  appear  to  have  been  established 
in  America  until  after  the  Revolution,  but  within  a 
few  years  following  the  conclusion  of  peace,  each  of 
the  three  chief  cities  in  the  United  States  had,  as  will 
be  seen,  followed  the  example  of  London  and  estab- 
lished a  Dispensary. 

Dispensaries  in  the  United  States 

The  first  was  started  in  Philadelphia  in  1786.  The 
Philadelphia  Dispensary  still  stands  on  Independence 
Square,  occupying  the  same  building  which  was 
erected  in  1801  and  which  with  slight  modifications 
serves  for  the  30,000  odd  patients  who  pass  through 
it  annually.  In  New  York  City  the  New  York  Dis- 
pensary was  established  in  1790  and  unlike  its  Quaker 
brother  has  passed  from  one  building  to  another, 
enlarging  as  it  moved.  The  third  Dispensary  in  the 
country  was  the  Boston  Dispensary,  established  in 
1796  at  a  point  on  Washington  Street,  close  to  the 
corner  of  Court  Street,  on  which  the  restaurant  known 
as  Thompson's  Spa  now  stands.  Those  responsible 
for  the  establishment  of  the  Boston  Dispensary  were 
familiar  with  the  institutions  in  New  York,  Philadel- 

*  By  1850  the  number  of  Dispensaries  in  London  is  said  to  have  in- 
creased to  35.  No  reference  is  made  here  to  Dispensaries  on  the  Con- 
tinent. They  do  not  appear  to  have  affected  the  early  development  of 
Dispensaries  in  the  United  States.  In  the  latter  part  of  the  nineteenth 
century,  foreign  clinics,  in  which  many  American  physicians  studied, 
had  substantial  influence  upon  the  procedures  of  medical  education, 
and  thus  upon  some  of  the  dispensary  movements  described  later  in 
this  chapter. 


HISTORICAL  6 

phia  and  London,  as  the  following  statement  prepared 
by  a  Committee  in  September,  1796,  bears  witness  i^ 
^'It  having  been  found  by  experience  both  in  Europe 
and  in  several  of  the  capital  towns  in  America,  that 
dispensaries  for  the  medical  relief  of  the  poor  are  the 
most  useful  among  benevolent  institutions,  a  number 
of  gentlemen  propose  to  establish  a  public  Dispensary 
in  the  town  of  Boston,  for  the  relief  of  the  sick  poor; 
which  they  presume  will  embrace  the  following  ad- 
vantages : — 

1.  The  sick,  without  being  pained  by  a  separation  from 
their  families,  may  be  attended  and  relieved  in  their  own 
houses. 

2.  The  sick  can,  in  this  way,  be  assisted  at  a  less  expense 
to  the  public  than  in  a  hospital. 

3.  Those  who  have  seen  better  days  may  be  comforted 
without  being  humiliated;  and  all  the  poor  receive  the 
benefits  of  a  charity,  the  more  refined  as  it  is  the  more  secret." 

The  benevolent  desire  to  help  the  sick  poor  thus 
appears  in  these  quaint  phrases  as  the  primary  motive 
leading  to  the  establishment  of  this  institution  and  it 
was  indeed  the  underlying  and  typical  motive  behind 
all  the  early  Dispensaries.  The  London  system  was 
maintained  in  the  three  earliest  American  Dispen- 
saries, requiring  that  patients  be  accepted  only  when 
recommended  by  subscribers,  printed  forms  being 
furnished  those  contributing  five  dollars  or  more  a 
year.  In  Boston,  a  subscriber  might  keep  two 
patients  under  care  for  each  five  dollars  annually  con- 
tributed. The  aim  was  to  give  the  subscriber  a  spirit- 
ual return  for  his  money  as  well  as  to  insure  ^^worthi- 


6  DISPENSARIES 

ness"  in  the  applicant.  That  the  '^ worthiness"  of 
the  applicant  was  emphasized,  appears  from  the  rule 
which  was  certainly  followed  in  Boston  and  probably 
elsewhere,  'Hhat  persons  suffering  from  venereal  dis- 
ease or  from  the  effects  of  alcohol  should  not  be  treated 
by  the  Dispensary,  as  being  the  victims  of  their  own 
sensual  indulgence. "    , 

The  early  Boston  Dispensary  consisted  merely  of  a 
drug  store,  with  a  physician  who  was  to  be  in  attendance 
daily  except  Sundays.  Ambulatory  cases  might  see 
him  there  at  11  o'clock.  Patients  too  sick  to  come  for 
treatment  were  to  be  visited  at  their  homes  and  to  a 
certain  extent  these  eighteenth  century  dispensary  phy- 
sicians saw  patients  at  their  private  offices  without 
charge.  Almost  the  sole  elements  of  expense  in  the 
early  days  were  the  medicines  provided,  and  of  these,  at 
least  at  the  Boston  Dispensary,  wines  or  spirits  were  the 
largest  items  among  the  treasurer's  bills.  The  method 
/  of  the  early  Dispensaries  was  simply  this :  a  poor 
I  patient  had  to  have  a  letter  from  a  subscriber,  and 
must  present  this  at  the  Dispensary  during  the  an- 
nounced hours ;  or  the  letter  of  recommendation  might 
be  left  by  some  friend  or  member  of  the  family  with 
the  apothecary,  so  that  the  doctor  should  have  the 
name  and  address,  in  order  to  call  at  the  sick  person's 
home.  At  first  only  one  physician  at  a  time  was  fur- 
nished. Dr.  John  Fleet,  the  first  physician  of  the 
Boston  Dispensary,  for  instance,  treated  80  patients 
during  the  first  year.  As  the  city  grew  in  size,  more 
physicians  were  added  and  the  city  was  divided,  each 
physician  seeing  patients  only  within  his  own  district. 


HISTORICAL  7 

In  New  York  additional  Dispensaries  were  founded 
early  in  the  nineteenth  century,  the  Northern  Dis- 
pensary (still  in  existence)  in  1827,  and  the  '' Eastern 
Dispensary '^  in  1832.  The  city  was  then  more  or  less 
equally  divided  between  them.  As  the  communities 
became  larger  the  earlier  system  of  recommending  pa- 
tients through  subscribers  became  increasingly  incon- 
venient and  was  gradually  given  up.  Dr.  Oliver  Wen- 
dell Holmes,  a  physician  of  the  Boston  Dispensary  in 
1837,  complained  in  a  letter  to  the  Board  of  Managers 
that  the  physicians  of  the  Dispensary  were  practically 
compelled  to  secure  tickets  signed  in  blank  by  sub- 
scribers. The  patients  usually  appealed  to  the  physi- 
cian in  the  first  instance  and  the  rule  requiring  that 
they  then  go  to  the  subscriber  and  secure  a  recommen- 
dation for  treatment  become  merely  vexatious.  The 
London  Dispensaries  and  the  New  York  Dispensary 
had  already  established  clinics  on  the  modern  principle 
by  which  the  physician  treats  ambulatory  cases  at  a 
given  time  and  place,  not  in  informal  conferences  at  the 
apothecary  shop.  Thus  the  system  of  recommending 
patients  by  subscribers  fell  into  disuse  and  was  finally 
abandoned,  and  clinics  as  we  know  them  today  were 
developed.  The  Boston  Dispensary  started  these 
clinics  in  1856. 

A  new  element  which  powerfully  reinforced  the 
charitable  desire  to  help  the  sick  poor  appeared  in 
the  dispensary  movement  during  the  first  part  of  the 
nineteenth  century,  namely,  the  interest  of  physicians 
in  acquiring  medical  experience  and  in  teaching  med- 
ical students  at   a  cHnic.     In  the. early  part  of  the 


8  DISPENSARIES 

nineteenth  century  the  teaching  of  medical  students 
was  carried  on  by  physicians  who  took  apprentices, 
as  it  were,  so  that  the  student  learned  the  practice  of 
medicine  by  taking  part  in  it,  under  the  tutelage  and 
practical  guidance  of  an  established  physician.  In 
connection  with  the  Boston  Dispensary  students  were 
allowed  to  attend  patients  almost  from  the  beginning, 
as  regulations  governing  the  activities  of  students 
appear  in  the  records  as  early  as  1827.  With  the  ad- 
vance of  medical  science  and  the  development  of 
medical  schools,  teaching  was  reorganized.  The  em- 
phasis upon  clinical  teaching  in  the  latter  part  of  the 
nineteenth  century,  instead  of  mere  didactic  instruc- 
tion, has  been  one  of  the  most  powerful  factors  in  increas- 
ing the  number  of  Dispensaries  and  improving  their 
work.  The  desire  to  provide  material  for  medical 
students  is  supplemented  in  the  physician's  mind  by 
the  endeavor  to  increase  his  own  skill  and  knowledge. 
The  teaching  motive  (or  m.edical-experience  motive) 
is  the  second  important  force  which  has  shaped  the 
development  of  Dispensaries.  Oliver  Wendell  Holmes 
wrote  a  report  to  the  Boston  Dispensary  in  1837,  after 
he  had  been  one  of  its  district  physicians,  and  urged 
the  establishment  of  a  clinic,  saying:^ — 

"A  consulting-room  well  attended  is  one  of  the  most 
valuable  schools  for  students  as  well  as  practitioners  of 
medicine,  since  many  cases  of  disease  may  be  seen  within  a 
very  limited  time;  and,  being  thus  collected,  may  be  com- 
pared with  and  illustrate  each  other.  This  is  one  of  the 
legitimate  ends  of  all  medical  charities. " 

Very  much  more  recently  we  see  the  charitable 


HISTORICAL  9 

motive  and  the  teaching  motive  balanced  in  the  utter- 
ance of  Sir  WiUiam  Osier,  in  his  address  at  the  opening 
of  the  new  Out-Patient  building  of  the  Cardiff  Hospital 
in  1908:^— 

''That  an  out-patient  department  is  simply  for  the  relief 
of  the  poor — the  common  idea — is  to  take  an  altogether  too 
narrow  view  of  its  functions.  ...  Of  course  the  first 
and  most  important  (function)  is  the  relief  of  the  poor. 
...  In  acting  as  the  training  school  for  the  younger 
members  of  the  profession,  the  out-patient  department 
fulfills  its  second  great  function.  .  .  .  With  sufficient  staff, 
there  is  no  reason  why  just  as  careful  notes  should  not 
be  taken  in  these  rooms  as  in  the  wards,  and  let  me  remind 
the  younger  physicians  in  the  audience  that  some  of  the 
most  brilliant  reputations  in  the  profession  of  this  country 
have  been  built  up  upon  the  solid  foundation  of  notes  taken 
in  out-patient  departments.  Let  me  urge  you  to  make 
ample  provision  for  your  medical  students  in  the  out- 
patient department,  where  they  see  the  patients  in  their 
native  state,  so  to  speak,  before  they  have  been  scoured  and 
cleansed  by  the  nurses  in  the  ward." 

The  modern  demand  that  medical  students  be 
taught  diagnosis  and  treatment  of  diseases,  in  the  only 
way  in  which  such  practical  matters  can  be  learned, 
i.e.,  by  experience  with  patients  themselves,  has  re- 
quired the  extensive  development  of  hospitals  and 
Dispensaries  in  connection  with  medical  schools. 
The  premier  hospitals  of  the  country  have  usually 
been  the  teaching  hospitals.  To  make  their  teaching 
facilities  adequate  it  has  been  needful  that  they  develop 
their  Dispensaries  or  out-patient  departments  (as  a 
Dispensary   connected   with   a  hospital  is   properly 


10  DISPENSARIES 

called).  The  teaching  motive  has  been  one  of  the 
most  important  stimuli  to  the  development  of  such 
great  historic  out-patient  departments  as  those  of  the 
Johns  Hopkins  Hospital  and  the  Massachusetts  Gen- 
eral Hospital. 

The  desire  of  medical  men  to  increase  their  own  ex- 
perience as  well  as  to  teach  students,  has  been  respon- 
sible for  many  Dispensaries,  particularly  those  for 
special  diseases,  such  as  those  of  the  eye,  nose,  throat 
and  ear.  The  out-patient  departments  of  lying-in 
hospitals,  special  clinics  for  children,  etc.,  have  been 
established  largely  because  of  the  desire  of  a  group  of 
specialists  to  advance  their  knowledge  and  technique. 
This  is  only  possible  when  a  mass  of  medical  material 
can  be  gathered  together.  The  public-spirited  motive 
to  perform  a  service  for  the  poor  joins  with  the  desire 
to  increase  medical  experience. 

The  two  motives  we  have  thus  far  analyzed,  to  do 
charity  and  to  advance  medical  knowledge  and  educa- 
tion, are  responsible  for  the  establishment  and  develop- 
ment of  the  majority  of  the  thousand  general  Dispen- 
saries in  the  country  today.  In  1800  there  were  three 
Dispensaries  in  the  United  States.  In  1900  there  were 
about  100.  Of  these  perhaps  75  were  general  Dispen- 
saries and  the  remainder  were  confined  to  the  treat- 
ment of  special  diseases.  Shortly  after  1900  new 
forces  entered  the  field,  developing  hundreds  of  new 
Dispensaries,  and  transforming  many  of  the  old. 
These  forces  are  outlined  in  the  next  chapter. 


HEALTH  AND  EFFICIENCY  11 


CHAPTER  II 

THE  PUBLIC  HEALTH  MOTIVE  AND  THE 
EFFICIENCY  IDEA 

Militant  organizations  to  combat  disease  are  a  new 
element  in  public  health  work.  When  the  growth  of 
scientific  knowledge  concerning  the  causation  and 
mode  of  transmission  of  a  prevalent  infectious  disease 
like  tuberculosis  has  reached  a  certain  point,  it  be- 
comes evident  that  power  hes  in  human  hands  to 
apply  this  knowledge  for  the  actual  diminution  if  not 
control  of  the  malady.  The  research  institutions  of 
the  scientist  are  at  this  point  supplemented  by  organ- 
ization for  practical  case-work  in  which  lay  as  well  as 
medical  men  co-operate.  Thus  upon  the  scientific 
foundations  laid  by  Pasteur  and  Koch,  in  the  last 
quarter  of  the  nineteenth  century,  the  anti-tubercu- 
losis campaign  arose  during  the  first  years  of  the 
twentieth.  In  the  United  States  it  assumed  organized 
shape  in  1905,  when  the  National  Association  for  the 
Study  and  Prevention  of  Tuberculosis  was  formed. 
Progress  since  that  time  has  been  remarkable.  To- 
day there  are  fifty  state-wide  anti-tuberculosis  organ- 
izations and  over  fourteen  hundred  local  associations 
and  committees  engaged  in  the  campaign.  The 
program  of  this  movement  has  included  two  essential 
elements : — 


12  DISPENSARIES 

1.  The  education  of  the  public:  achieved  through  all  sorts 
of  educational  propaganda,  from  lectures  and  moving  picture 
shows  to  advertising  leaflets  and  Red  Cross  Seals:  also 
through  the  personal  educational  work  of  the  Visiting  Nurse, 
the  chief  field  agent  of  the  whole  campaign.  The  educa- 
tional influence  upon  the  medical  profession  itself  is  an  ad- 
ditional feature  of  importance. 

2.  The  increase  of  facilities  for  the  diagnosis  and  treatment 
of  the  disease.  In  1905  there  were  approximately  600  hos- 
pital or  sanitorium  beds  for  tuberculosis  cases  in  the  United 
States.  In  1915  there  were  over  30,000  beds.  In  1905 
there  were  20  tuberculosis  clinics  or  Dispensaries  in  the 
United  States;  twelve  years  later  there  were  over  500. 

It  is  the  eflfect  of  the  anti-tuberculosis  movement 
upon  the  growth  of  treatment  facilities  and  particu- 
larly upon  Dispensary  clinics  that  claims  our  atten- 
tion. We  may  note  also  that  in  the  official  program 
of  the  National  Association,  proclaiming  what  ought 
to  be  achieved  by  1925,  there  is  included  the  demand 
for: — 

"cUnics  in  every  city  or  county,  so  that  anyone  who  sus- 
pects he  has  tuberculosis  may  be  examined  and  treated,  free 
of  charge  if  he  cannot  afford  medical  care. " 

The  anti-tuberculosis  movement  has  thus  been  re- 
sponsible for  the  establishment  of  some  five  hundred 
Dispensaries  for  this  disease  in  the  United  States 
and  within  the  next  few  years  the  number  will  run 
into  the  thousands,  for  many  states  are  establishing 
them  by  law  in  every  city,  town  or  county.  For  our 
purpose  we  must  dwell  upon  the  motive  underlying 


HEALTH  AND  EFFICIENCY  13 

this  development.  This  motive  is  not  that  of  provid- 
ing care  for  the  poor,  nor  medical  advantages  for 
physicians  or  students,  but  is  a  direct  endeavor  to 
combat  disease  and  promote  public  health.  The  Dis- 
pensary is  regarded  by  the  anti-tuberculosis  movement 
as  a  public  health  agent,  partly  educational  and  partly 
for  the  purpose  of  diagnosing  or  treating  cases  of  dis- 
ease. The  conscious  establishment  of  dispensary  clinics 
for  public  health  motives  may  be  regarded  as  having 
originated  in  this  country  through  the  anti-tuberculosis 
movement. 

It  has  not  stopped  there,  however.  Recent  years 
have  brought  forth  other  campaigns  along  the  same 
lines.  First  may  be  named  the  campaign  to  '^save 
babies."  Starting  with  some  local  efforts,  it  devel- 
oped in  1909  into  the  National  Association  for  the 
Study  and  Prevention  of  Infant  Mortality.  The 
same  two  elements  appeared  as  in  the  anti-tubercu- 
losis movement,  namely,  the  education  of  the  medi- 
cal and  lay  public  and  the  enlargement  of  facilities 
for  the  diagnosis  and  treatment  of  babies  and  little 
children.  Dispensaries  and  out-patient  departments 
for  pediatric  work  with  sick  babies  have  been  stimu- 
lated, but  more  than  that,  a  great  number  of  new 
clinics  have  been  founded,  for  '^well  babies,"  sick 
babies,  or  both.  In  1915  there  were  at  least  538  such 
clinics  in  141  cities  of  over  10,000  population  in  the 
United  States.  This  is  five  times  as  many  as  existed 
in  1910.  Here  also  a  rapid  increase  may  be  expected, 
for  the  studies  and  publications  of  the  United  States 
Children's  Bureau,  and  many  private  agencies,  are 


14  DISPENSARIES 

spreading  the  movement  to  prevent  infant  mortality 
into  the  smaller  communities  and  rural  districts. 

Another  public  health  movement  of  major  import 
has  been  that  to  promote  the  health  of  school  children. 
Medical  school  inspection  began  with  the  endeavor  to 
control  contagious  diseases  among  children  in  the 
public  schools,  but  has  broadened  far  beyond  its  orig- 
inal scope.  Periodical  examination  of  children  at 
once  reveals  physical  defects,  particularly  of  the  teeth, 
eyes,  nose  and  throat ;  while  many  general  medical  or 
surgical  disorders  are  also  found.  The  correction  of 
defects  of  eyesight,  the  care  of  the  teeth  and  the 
removal  of  enlarged  tonsils,  require  the  service  of  spe- 
cialists ;  and  as  a  considerable  proportion  of  parents  of 
public  school  children  are  not  able  to  pay  the  cost,  there 
is  a  demand  upon  dispensary  clinics  if  any  exist  in  the 
community;  or  a  demand  to  establish  special  clinics 
if  the  existing  provisions  are  insufficient.  Medical 
school  inspection  is  responsible  for  the  foundation  of 
many  dental  clinics.  A  few,  like  the  Forsyth  Dental 
Infirmary  in  Boston,  are  large  institutions;  but  most 
are  small  local  clinics,  some  in  school  buildings.  A 
certain  number  of  eye  and  throat  clinics  have  been 
established  also.  In  communities  wherein  Dispen- 
saries already  existed,  medical  school  inspection  has 
supplied  a  new  and  powerful  stimulus  to  the  dental, 
eye,  throat,  ear,  orthopedic,  and  general  clinics  deal- 
ing with  children. 

The  study  of  insanity  and  of  mental  defects  has  led 
to  the  foundation  of  national  and  local  Committees  on 
Mental  Hygiene.     It  is  now  understood  that  it  is 


HEALTH  AND  EFFICIENCY  15 

desirable  to  get  hold  of  mental  disease  in  early  stages 
and  that  there  is  economy  in  providing  after-care  for 
the  discharged  patients  of  insane  hospitals.  Hence 
a  growing  number  of  psychiatric  clinics  have  been 
founded.  Of  these  the  most  prominent  are  institu- 
tions like  the  Phipps  Clinic  in  Baltimore  and  the 
Boston  Psychopathic  Hospital,  but  in  New  York  and 
in  Massachusetts  out-patient  clinics  for  mental  dis- 
eases have  been  begun  in  connection  with  the  insane 
hospitals.  Massachusetts  has  moved  among  the 
farthest,  establishing  a  chain  of  such  clinics  all  over 
the  Commonwealth.  The  time  is  approaching  when 
no  system  of  hospitals  for  the  insane  will  be  considered 
adequate  unless  it  is  supplemented  by  a  set  of  local 
out-patient  clinics  for  preventive  and  follow-up  work. 
Interest  in  controlling  and  preventing  venereal  dis- 
ease has  followed  the  same  course.  It  has  led  to  a 
national  organization  and  some  twenty  state  societies 
dealing  with  the  subject.  Education,  law-enforce- 
ment, and  the  treatment  and  prevention  of  disease  are 
included  in  their  program.  These  societies  are  approach- 
ing venereal  disease  from  the  viewpoint  of  a  health 
problem.  They  have  been  met  more  than  half-way 
by  progressive  pubhc  health  officials,  who  are  actively 
taking  up  the  venereal  problem  in  New  York,  Buffalo, 
Rochester,  Cleveland,  Chicago  and  elsewhere.  In 
New  York  the  Associated  Out-Patient  Clinics  have 
utilized  the  growing  interest  in  the  control  of  syphihs 
and  gonorrhea  to  support  standards  for  the  equipment 
and  maintenance  of  venereal  clinics.  Chnics  for 
diagnosis  of  these  diseases  have  been  started  by  the 


16  DISPENSARIES 

A    Department  of  Health  in  the  same  city  and  are  devel- 
j  oping  elsewhere.     Clinics  for  treatment  have  been 
\  begun  under  municipal  auspices  in  Buffalo,  and  pay 
I  clinics  under  private  auspices  in  Boston,  Brooklyn, 
I  Cleveland  and  elsewhere.     The  time  is  near  when  we 
I  shall  see  the  demand  for  out-patient  clinics,  as  health 
measures  for  controlling  syphilis  and  gonorrhea,  made 
part  of  the  accepted  program  of  the  organizations 
which  are  combating  these  diseases,  just  as  tubercu- 
losis clinics  have  been  incorporated  into  the  platform 
I  of  the  anti-tuberculosis  campaign.*    The  report  of  the 
British  Royal  Commission  on  Venereal  Disease  in 
1915  has  led  to  far-reaching  programs  for  the  prophy- 
laxis and  treatment  of  syphilis  and  gonorrhea  in  Great 
Britain,  in  which  dispensary  clinics  now  play  a  large  part. 
Economic  self-interest  has  recognized  the  value  of 
the  out-patient  clinic  in  providing  care  for  workmen. 
In  some  industrial  establishments  these  clinics  are 
elaborate  organizations  with  permanent  salaried  med- 
ical staff;  in  others,  they  are  merely  accident  or  first- 
aid  rooms.     Their  motive  in  either  case  is  to  cure 
disease  and  to  promote  health  among  the  workers,  be- 
cause this  means  the  saving  of  human  waste  and  a 
higher  working  efficiency. 

Thus  in  many  fields  we  have  traced  parallel  develop- 
ments. In  the  case  of  tuberculosis,  in  the  diseases  of 
school  children  or  of  babies,  in  mental  disease,  venereal 
disease,  etc.,  the  resources  of  private  medical  practice 

\      *  Since  this  was  written,  the  War  program  for  the  treatment  and 
'  control  of    venereal    disease  has  brought  an  extraordinary  advance. 
The  establishment  of  clinics  and  of  educational  and  regulative  meas- 
ures have  gone  forward  apace. 


HEALTH  AND  EFFICIENCY  17 

have  been  found  insufficient  to  meet  the  needs  for 
diagnosis  and  treatment;  and  as  a  result  each  public 
health  campaign  has  undertaken  and  is  undertaking 
to  enlarge  the  facilities  of  existing  dispensary  clinics; 
to  raise  their  standards  of  administration ;  and  also  to 
establish  new  clinics.  Dispensaries  stimulated  by 
such  a  motive  have  dealt  with  the  disease  as  a  public 
health  problem  rather  than  as  a  problem  depending 
upon  the  moral  or  the  financial  situation  of  the  indi- 
vidual sufferer.  As  we  shall  see,  the  public  health 
motive  influences  the  method  of  conducting  Dispen- 
saries— an  influence  which  we  shall  trace  in  detail 
later  in  this  book. 

With  the  development  of  many  forms  of  specialized 
work  and  its  public  health  application  by  means  of 
Dispensaries,  nurses  and  other  sociologic  methods, 
there  has  come,  and  will  progressively  come,  the  prob- 
lem of  organizing  these  specialties  and  using  them  in 
correlation.  It  is  not  possible  to  continue  the  devel- 
opment of  clinics,  nurses  and  other  machinery  for 
tuberculosis,  for  acute  contagion,  for  babies,  for 
school  children,  for  mental  disease,  for  venereal  dis- 
ease, for  other  problems  about  to  appear,  in  separate 
and  independent  organizations.  Failure  will  neces- 
sarily come  from  the  weight  of  the  machinery. 

As  each  special  problem  becomes  recognized  as 
such  by  society,  and  the  immediate  methods  of  pro- 
cedure become  fairly  well  understood,  it  must  be  in- 
corporated into  the  general  public  health  activities  of 
the  community.  There  is  no  longer  need  for  a  mul- 
tipHcity  of  special  nurses,  special  cUnics,  or  special 


18  DISPENSARIES 

organizations.  The  Health  Center  Idea,  aiming  to 
co-ordinate  all  the  special  public  health  services  in  each 
district,  represents  this  needed  movement  for  correla- 
tion. How  it  is  taking  actual  shape  in  many  commu- 
nities later  chapters  will  show. 

Closely  related  to  the  public  health  motive  is  an- 
other conception  in  the  dispensary  field  which  has  re- 
cently become  prominent: — the  efficiency  idea.  The 
conscious  study  of  efficiency  in  organization  has  been 
much  exploited  in  business.  Its  application  to  hos- 
pitals and  Dispensaries  grew  from  the  thoughtful 
initiative  of  a  few  physicians  and  superintendents,  who 
as  medical  men  or  executive  officers  saw  a  need  and  an 
opportunity. 

Efficiency  in  doing  things  can  be  judged  only  after 
we  have  clearly  in  mind  the  aim  of  our  accomplish- 
ment. So  long  as  that  aim  is  chiefly  the  acquiring  of 
medical  experience,  we  are  likely  to  have,  unless 
special  organized  provision  is  made  to  counteract  the 
tendency,  a  situation  described  ten  years  ago  by  Dr. 
Richard  C.  Cabot^  as  follows: — 

''In  order  to  make  it  worth  while  for  an  able  (and  there- 
fore busy)  physician  to  give  tirae  to  dispensary  work,  you 
must  allow  him  the  privilege  of  skimming  the  cream  off  the 
clinic:  that  is,  of  controlling  and  rushing  through  a  rela- 
tively large  number  of  patients  for  the  sake  of  the  few  in- 
teresting cases  to  be  found  in  the  bunch.  The  physician 
takes  his  pay  in  this  form.  He  uses  a  dispensary  clinic  to 
furnish  interesting  cases  for  teaching  or  for  scientific  study. " 

The  paper  from  which  this  is  quoted,  read  by 
Dr.   Cabot  before  the   Maryland   Medical   Society, 


HEALTH   AND  EFFICIENCY  19 

December  4,  1906,  is  a  landmark  in  the  recent  history 
of  dispensary  work.  The  paper  as  a  whole  recognizes 
clearly  that  securing  results  in  the  treatment  of  the 
patient  is  the  prime  public  aim  of  Dispensary  work, 
and,  what  is  less  obvious  and  more  important,  that 
the  organization  of  the  Dispensary  must  be  definitely 
shaped  to  this  end. 

A  superintendent  of  a  great  hospital.  Dr.  S.  S. 
Goldwater,  expressed  the  same  idea  with  a  different 
application,  in  his  equally  significant  address  on  ''Dis- 
pensary Ideals,"  printed  in  the  American  Journal  of 
the  Medical  Sciences  in  September,  1907.^  Dr.  Gold- 
water  was  impressed  with  the  same  hurry  and  over- 
crowding in  dispensary  clinics  to  which  Dr.  Cabot 
referred.  He  also  urged  efficient  treatment  and 
he  also  suggested  certain  practical  steps  towards 
securing  it.  Dr.  Cabot's  proposal  was  to  provide 
social  workers  to  give  individual  attention  to  the  case 
of  each  patient  and  thus  supplement  and  counteract 
the  necessarily  brief  time  given  by  the  physician. 
This  personal  or  case-work  method  is  the  characteristic 
reaction  of  the  clinical  physician.  Dr.  Goldwater's 
chief  proposition  was  that  the  number  of  patient^ 
should  be  limited;  he  even  proposed,  and  actually 
carried  out  in  Mt.  Sinai  Hospital,  the  radical  step  of 
preventing  more  than  a  certain  number  of  patients 
going  from  the  admission  desk  to  a  clinic  within  a 
given  time.  This  proposal  was  characteristic  of  an 
executive  and  organizer. 

Attention  to  personal  relationships  between  the 
physician  and  the  patient;  attention  to  the  organiza- 


20  DISPENSARIES 

tion  of  the  institution  as  a  whole  so  as  to  secure  effi- 
ciency in  treatment:  these  two  fundamental  aspects 
of  efficient  work  in  Dispensaries  were  thus  brought 
out  at  practically  the  same  time  by  two  pioneers  in 
the  movement  for  better  dispensary  service.  A  fur- 
ther step  was  taken  in  1912  at  the  Boston  Dispensary,^ 
where  tests  were  devised  for  measuring  medical  effi- 
ciency in  certain  aspects.  Imperfect  as  such  tests 
were,  they  placed  a  new  power  in  the  hands  of  the 
physician  or  the  superintendent  of  a  Dispensary, 
because  they  gave  him  means  to  estimate  results  and 
to  try  out  various  methods  by  which  results  might 
be  improved.  The  most  important  feature  of  any 
efficiency  test  is  the  attitude  of  mind  which  it  creates 
in  making  it.  The  impersonal  judging  of  results,  and 
the  critical  experimentation  with  methods  as  tested 
by  results,  are  a  sine  qua  non  of  scientific  progress  in 
any  field. 

The  efficiency  idea  is  responsible  for  the  rise  of  a 
new  conception,  namely,  that  dispensary  work  is  an 
organized  form  of  medical  service  which  may  be 
broadly  applied.  The  co-operative  work  of  special- 
ists, in  the  modern  hospital,  has  impressed  many 
thoughtful  physicians  with  the  advantages  of  the  joint 
use  of  expensive  laboratories  and  other  equipment, 
and  of  the  opportunity  for  consultation  and  team- 
play  which  can  be  best  afforded  when  the  various 
specialists  are  at  work  in  the  same  building  at  the  same 
time.  The  Dispensary  represents  the  same  principles 
of  organization  applied  to  ambulatory  instead  of  to 
bed  cases.     Can  we  not,  in  the  Dispensary,  test  out 


HEALTH  AND  EFFICIENCY  21 

the  possibilities  of  organized  medical  service,  as  dis- 
tinguished from  the  traditional  individuahstic  service 
of  private  practice?  In  other  words,  what  is  the  most 
efficient  form  of  medical  organization?  The  physi- 
cians and  laymen  who  are  working  out  an  answer  to 
these  questions  are  no  longer  thinking  of  the  Dispen- 
sary as  a  place  in  which  medical  experience  is  to  be 
gained  or  imparted,  nor  as  an  institution  of  charity. 
That  both  of  these  functions  have  their  place,  is  well 
recognized,  but  they  are  both  included  in  the  larger 
conception  of  the  Dispensary  as  an  organization  for 
the  efficient  rendering  of  medical  service,  either  cura- 
tive (clinical)  or  preventive  (public  health)  service. 
The  technical  methods  by  which  its  possibilities  shall 
be  developed  and  also  its  limitations  defined,  are  the 
joint  task  of  all  those  who  work  thoughtfully  in  Dis- 
pensaries, whether  as  physicians,  as  lay  helpers,  or  as 
administrators. 

The  efficiency  idea  applied  to  dispensary  services 
comes  to  full  fruition  in  organizations  formed  for  the 
co-ordinated  practice  of  medicine  on  a  scientific  but 
business  basis.  The  Mayo  Clinic,  at  Rochester,  Minn- 
esota, is  simply  a  large  Dispensary,  receiving  about 
the  same  number  of  patients  per  year  as  the  Boston 
Dispensary,  but  run  as  a  business  enterprise  by  a  group 
of  doctors,  with  W.  J.  Mayo  and  Charles  H.  Mayo  at 
their  head.  This  institution  was  not  founded  as  a 
charity,  nor  as  a  center  for  medical  teaching,  nor  for 
public  health  purposes ;  although  it  serves  all  these  aims 
in  certain  measure.  It  was  established  and  is  main- 
tained for  the  efficient  practice  of  medicine  and  must 


22  DISPENSARIES 

compete  with  private  practitioners  and  with  other 
Dispensaries  on  a  basis  of  efficiency.  The  Mayo 
Chnic,  and  other  smaller,  less  known,  but  increasing 
examples  of  the  same  type,  bear  witness  to  the  possi- 
bilities of  the  Dispensary  as  a  form  of  organization  for 
^Hhe  efficient  rendering  of  medical  service. ''* 

Organizations  especially  formed  to  advance  the 
technique  and  standards  of  dispensary  service  have 
recently  appeared.  First  in  the  field  was  the  Associ- 
ated Out-Patient  Clinics  of  New  York,  estabUshed  in 
February,  1912,  largely  through  the  interest  and 
initiative  of  Dr.  Goldwater.  It  is  a  co-operative 
association  of  dispensaries  and  out-patient  depart- 
ments, its  stated  purpose  being : — 

(a)  To  co-ordinate  the  work  of  the  institutions  in  New 
York  City. 

(b)  To  prevent  the  abuse  of  dispensaries  by  persons  not 
properly  entitled  to  receive  treatment. 

(c)  To  establish  clinical  standards. 

(d)  To  promote  economy  and  efficiency  in  the  manage- 
ment of  Dispensaries. 

This  Association  has  published  a  number  of  valuable 
studies  and  standards  relating  to  various  departments 

*  The  rapid  growth  of  Dispensaries  has  naturally  given  rise  to  a  small 
number  of  undesirable  institutions.  Some  of  these  masquerade  as 
charities,  although  really  conducted  for  the  benefit  of  their  owners  or 
managers.  Others  are  commercial  enterprises  of  an  illegitimate  or  ex- 
ploitative sort.  The  public  has  so  direct  an  interest  in  any  institution 
which  deals  or  pretends  to  deal  with  disease,  that  all  dispensaries  should 
be  subject  to  some  supervision  or  regulation  by  a  local  or  state  authority. 
The  form  which  such  regulation  may  well  take  is  outlined  in  Chapter 
XIII. 


HEALTH  AND  EFFICIENCY  23 

of  Dispensaries,  to  which  reference  will  be  made  in 
other  chapters  of  this  book.® 

Second  in  order  was  the  Committee  on  Dispensary 
Work  of  the  American  Hospital  Association,  organized 
after  the  annual  convention  of  that  body  in  September, 
1913.    This  Committee  has  undertaken: — 

(a)  Studies  of  the  growth  in  number  and  extent  of  Dis- 
pensaries in  the  United  States. 

(b)  Study  of  special  problems  and  of  different  types  of 
Dispensaries. 

(c)  Certain  elementary  standards  of  organization  and 
management  have  been  formulated,  and  promulgated 
through  the  publications  of  the  American  Hospital  Associa- 
tion. 

(d)  Through  an  annual  questionnaire,  new  features  in 
dispensary  work  have  been  collected  and  published  in  the 
Committee's  Annual  Report. 

Thus  Dispensary  work  has  entered  a  self-conscious 
stage.^  Behind  its  growth  in  this  country,  we  have 
traced  four  main  impelling  forces,  arranged  in  the 
order  of  their  development  thus : — 

(1)  The  charity  motive,  interested  in  the  patient  as  a  mem- 
ber of  a  dependent  group  that  needs  help. 

(2)  The  medical  motive,  interested  primarily  in  diagnosis 
and  in  medical  teaching.  Interest  in  treatment  is  not 
absent  but  the  emphasis  has  been  on  the  diagnostic  side. 

(3)  The  public  health  motive,  interested  in  the  patient  not 
as  a  bundle  of  diseases,  nor  as  an  object  of  charity,  but  as  a 
citizen,  and  establishing  dispensaries  to  further  the  cure, 
control  and  prevention  of  disease. 

(4)  The  economic  motive,  interested  in  the  co-ordinated 

3 


24  DISPENSARIES 

practice  of  medicine,  and  utilizing  the  dispensary  organiza- 
tion as  an  efficient  means  to  this  end. 

The  four  motives  are  in  themselves  not  inconsistent. 
They  supplement  one  another.  They  do  pull  in  dif- 
ferent directions,  but  they  are  capable  of  being  co- 
ordinated and  jointly  utilized  for  a  common  aim.  The 
efficiency  idea  aims  to  utilize  all  of  them,  each  in  its 
place,  by  applying  scientifically  the  general  principles 
of  organization  to  the  special  problems  of  medical 
institutions.  The  ultimate  guiding  forces  in  Dispen- 
saries must  include  the  spirit  of  human  service,  oppor- 
tunity to  widen  medical  knowledge  and  experience, 
and  power  to  serve  the  health  of  the  community  by 
efl&cient  treatment  and  aggressive  prevention  of  dis- 
ease. 

To  show  how  this  analysis  is  justified  through  a 
study  of  existing  Dispensaries  and  how  it  illuminates 
their  problems;  to  indicate  the  ways  in  which  some  of 
these  problems  may  be  solved;  and  to  suggest  direc- 
tions in  which  Dispensaries  may  move  toward  more 
efficient  and  more  inclusive  public  service:  these  are 
the  essential  endeavors  of  this  volume. 


SCOPE  AND  EXTENT  25 


CHAPTER   III 

PRESENT  SCOPE  AND  EXTENT  OF  DISPENSARIES 
IN   THE  UNITED   STATES 

I.  What  is  a  Dispensary? 

When  the  little  doctor  in  '^V.  V/s  Eyes'*  is 
pictured  by  the  novelist  seated  in  his  office  with  one 
poor  patient  in  front  of  him  and  a  long  row  of  others  in 
the  waiting  room,  the  reader  may  well  ask  himself 
whether  '^V.  V."  is  not  running  a  Dispensary. 
But  ^'V.  V.''  was  running  his  office  on  his  own  hook, 
while  a  Dispensary,  large  or  small,  is  essentially  an 
organization.  When  a  person  who  is  in  comfortable 
circumstances  becomes  seriously  ill,  his  doctor  will  call 
to  see  him  in  his  home.  If  he  is  not  too  ill  to  venture 
from  the  house  he  will  go  to  see  the  doctor  at  the  latter's 
office.  A  Dispensary  is  simply  an  organization  with  a 
definitely  known  system  of  office  hours  at  which  people 
may  go  to  consult  doctors.  As  we  have  seen  from  the 
historical  sketch,  Dispensaries  began  in  the  English- 
speaking  world  as  places  for  distributing  medicines, 
and  received  their  name  from  this  form  of  dispensa- 
tion; and  they  were,  and  still  mostly  are,  established 
to  receive  the  poor.  Yet  neither  the  distribution  of 
medicines  nor  the  limitation  of  their  service  to  those 
unable  to  pay,  are  now  necessary  parts  of  the  definition 
of  a  Dispensary,  for  there  are    many    Dispensaries 


\ 


26  DISPENSARIES 

which  do  not  furnish  medicines,  and  some  which 
charge  fees  above  the  reach  of  the  poor.  But  the 
essential  definition  of  a  Dispensary  today  is  that  it  has 
doctors  and  an  organized  system  by  which  patients  are 
received  and  cared  for.  Like  the  hospital,  the  Dis- 
pensary is  an  institution,  but  the  hospital  wards  re- 
ceive patients  who  cannot  be  up  and  about,  while  the 
Dispensary  is  for  those  who  can  go  out  to  see  a  doctor, 
as  to  a  private  office.  Such  patients  are  called  in 
technical  language,  ambulatory  cases.  An  institution 
with  an  organized  system  of  office  hours  for  the  medical 
examination  and  treatment  of  ambulatory  cases,  is  a 
useful  preliminary  working  definition  of  a  Dispensary, 
but  does  not  cover  all  of  its  essential  features. 

At  a  small  Dispensary  treating  only  a  particular 
disease,  such  as  tuberculosis,  and  serving  only  a  local 
area,  there  may  be  but  a  single  doctor,  who  does  all  the 
work,  much  as  ^'little  V.  V."  did  in  Harrison's  story. 
In  all  but  the  smallest  Dispensaries,  however,  there 
are  a  number  of  doctors  and  they  are  organized  in  a 
particular  way.  There  is  division  of  labor  among 
them.  The  ^'general  medical"  man  or  ''internist," 
the  surgeon,  the  oculist,  the  laryngologist,  the  ortho- 
pedist, the  children's  specialist,  the  dentist,  the  neurol- 
ogist, and  others,  work  together.  Hence  efficiency 
demands  that  a  new  element  should  appear,  that  of 
medical  organization,  and  this  is  twofold :  the  organiza- 
tion of  equipment  and  the  organization  of  skill.  Modern 
medicine  demands  laboratories.  X-ray  apparatus, 
microscopes,  and  instruments  of  many  kinds.  This  " 
expensive  equipment  is  available  to  more  doctors,  and 


SCOPE  AND  EXTENT  27 

is  available  on  better  terms,  if  it  is  concentrated  in  one 
building  and  arranged  or ''  organized  "  under  one  coher- 
ent plan,  than  if  it  is  scattered  among  a  dozen  or  three 
dozen  separate  and  independent  offices.  Still  more 
important  in  modern  medicine  is  the  factor  of  special 
skill.  The  comic  papers  make  fun  of  doctors  each  of 
whom  treats  only  one  small  region  of  the  body,  and 
they  depict  the  plight  of  the  patient  who  is  sent  from 
one  specialist  to  another,  while  his  bills  and  his  confu- 
sion mount  together.  There  is  no  good  reason  to  make 
fun  of  the  specialist,  for  he  is  necessary.  There  is 
reason  to  make  fun  of  the  use  of  specialists  in  an  un- 
organized way.  The  hospital  and  the  Dispensary 
stand  for  the  principle  of  organization,  as  distin- 
guished from  the  very  slightly  tempered  individualism 
of  private  practice. 

We  shall  trace  these  contrasts  further,  and  their 
bearing  upon  the  practice  of  medicine,  in  later  chapters. 
Here  we  may  point  out  how  they  bear  on  the  definition 
of  a  Dispensary.  They,  in  fact,  supply  one  of  the 
essential  factors  in  the  definition.  A  Dispensary  is  an 
institution  which  organizes  the  professional  equipment 
and  special  skill  of  physicians  for  the  diagnosis,  treat- 
ment and  prevention  of  disease  among  ambulatory 
patients.  This  definition  will  serve  us  throughout 
this  volume. 

To  avoid  misapprehension,  certain  other  terms 
perhaps  require  definition,  particularly  Clinic.  A 
Clinic  may  be  defined  as  a  division  of  a  Dispensary  in 
which  a  specified  group  of  related  diseases  are  treated. 
Thus  the  patients  coming  to  a  Dispensary  will  be 


28  DISPENSARIES 

divided  according  to  their  troubles  among  the  Medical, 
Surgical,  Pediatric,  Neurological,  Opthalmological 
Clinics,  etc.  The  word  Department  is  sometimes  used 
as  if  synonymous  with  Clinic,  but  is  administrative 
rather  than  medical.  There  are  also  Departments  of  a 
Dispensary  which  are  not  Clinics  at  all,  such  as  the 
Laboratory,  the  Pharmacy,  or  Social  Service. 

2.  The  Medical  Scope  of  Dispensaries 

A  man  slips  on  the  stairs  after  breakfast  one  morn- 
ing, and  walks  into  the  Dispensary  one  hour  later  with 
a  cut  arm  and  broken  collar-bone.  An  old  fellow 
with  a  "weak  heart"  calls  often  at  the  Dispensary  for 
the  advice  and  medicine  which  enable  him  to  work 
enough  to  live.  The  public  school  doctor  finds  a  child 
of  twelve  with  poor  eyesight  and  bad  teeth.  The 
Dispensary  will  provide  the  expert  optical  and  dental 
service  which  the  parents  cannot  pay  for,  and  which 
the  child  must  have  to  profit  by  its  education.  A 
young  working-girl  comes  with  ^'debility."  Without 
care  the  white  plague  will  lay  its  hand  upon  her  soon. 
Pneumonia  and  typhoid  fever,  cancer,  appendicitis  and 
tuberculosis  appear  in  dispensary  clinics.  To  detect 
these  diseases  in  early  stages  when  they  can  be  most 
successfully  dealt  with;  or  to  secure  prompt,  efficient 
hospital  care,  if  this  is  necessary,  saves  time,  money, 
suffering,  often  hfe  itself.  The  earlier  acts  of  the 
drama  of  disease  are  thus  those  more  usually  seen  at 
the  dispensary  clinic,  whereas  hospital  beds  and  physi- 
cians treating  patients  in  their  own  homes,  more  usu- 
ally witness  disease  at  its  dramatic  climax.     Of  course 


SCOPE  AND   EXTENT  29 

serious  sickness  may  appear  in  a  Dispensary,  calling 
for  reference  to  a  hospital,  or  to  the  care  of  a  physician 
in  bed  at  home. 

Roughly  classified,  the  typical  medical  field  of  the 
Dispensary  may  be  said  to  include  the  following  :io 

1.  Minor  surgical  accidents. 

2.  Serious  diseases: 

a.  In  their  early  and  often  preventable  stages. 

b.  In  chronic  or  convalescent  stages. 

3.  Certain  serious  diseases  which  do  not  usually  require 

any  period  of  bed  treatment;  e.g.,  gonorrhea,  syphilis. 

4.  Diseases  of  special  organs;  e.g.,  the  eyes,  the  ears,  the 

teeth,  the  throat,  etc. 

5.  Developmental  defects  of  childhood. 

6.  Minor  diseases.     Often  these,  if  not  properly  cared  for, 

will  diminish  earning  capacity,  or  lessen  resisting 
power,  so  as  to  lay  the  way  open  to  serious  disease. 

A  brief  summary  will  show  the  practical  bearing  of 
this  enumeration. 

1.  Minor  surgical  accidents  constitute  a  considerable  part 
of  the  '^ medical  material"  at  many  Dispensaries.  Prompt, 
efficient  treatment  of  these  accidents  means  the  saving  of 
large  sums  of  money  by  reducing  the  period  during  which  an 
employee  is  incapacitated. 

2.  Modern  medicine  has  emphasized  the  importance  of 
diagnosing  and  treating  serious  diseases  in  their  early  stages 
whenever  possible.  In  a  Dispensary,  cancer,  heart  disease, 
kidney  troubles,  digestive  and  intestinal  disorders,  and 
tuberculosis,  appear  early  in  their  course.  Many  of  the 
acute  functional  disorders  of  earty  childhood,  particularly 
the  gastro-intestinal  and  the  respiratory,  fall  within  the 


30  DISPENSARIES 

special  province  of  the  Dispensary.  In  an  efficiently  con- 
ducted Dispensary  with  adequate  laboratory  facilities, 
accurate  and  early  diagnosis  of  these  troubles  is  practicable. 
The  Dispensary  thus  has  a  function  of  the  utmost  import- 
ance from  the  standpoint  of  the  public  health,  and  not  at  all 
dependent  upon  its  relation  to  the  hospital:  the  function  of 
detecting  serious  disease  in  its  early  and  often  preventable 
stages. 

3.  There  are  two  diseases,  of  the  first  importance,  which 
the  Dispensary  may  almost  be  said  to  have  for  its  peculiar 
province;  gonorrhea  and  syphilis.  The  complications  of 
gonorrhea  and  the  later  manifestations  of  syphilis  bring 
many  patients  to  hospital  wards.  Yet,  large  though  the 
number  of  these  bed-patients  is,  they  represent  only  a  frac- 
tion of  the  total  who  suffer  from  the  venereal  scourges.  The 
large  majority  demand  treatment  as  ambulatory  cases. 
This  treatment  is  secured  in  one  of  four  ways : 

1.  From  private  physicians  in  their  offices. 

2.  At  dispensary  clinics. 

3.  In  the  offices  of  advertising  doctors,  or  at  medical 

"institutes"    or    by    correspondence    with    such 
''institutes." 

4.  Self-treatment — the  patient  prescribing  for  himself 

on  advice  obtained  from  friends,  from  literature,  or 
from  drug  clerks,  with  drugs  bought  at  pharmacies. 

No  one  knows  the  relative  proportion  of  patients  who 
secure  treatment  through  each  of  these  four  sources,  but 
three  points  are  clear:  (a)  the  last  two  agencies  of  treat- 
ment are  thoroughly  undesirable;  (b)  they  are  widely 
used;  (c)  this  fact  is  evidence  that  the  desirable  agencies  of 
treatment  are,  for  one  reason  or  another,  not  adequate  to 
the  immediate  existing  needs. 

Under  the  present  and  the^probable  future  conditions  of 


SCOPE  AND  EXTENT  31 

private  medical  practice,  American  communities  may  find, 
as  Great  Britain  is  now  finding,  that  the  enlargement  of 
Dispensary  facilities  is  the  only  means  by  which  adequate 
opportunities  for  treating  venereal  disease  can  be  provided. 
4,  5  and  6.  What  are  commonly  called  ''minor  diseases" 
often  have  more  than  minor  effects  upon  the  health  and 
working  efficiency  of  the  sufferer.  Such  diseases,  which  do 
not  confine  the  patient  to  his  bed,  fall  particularly  within 
the  province  of  the  Dispensary:  for  example,  many  skin 
diseases,  very  troublesome,  and  in  some  instances  infectious; 
the  common  cold  and  its  sequels;  nervous  disturbances; 
digestive  disorders;  septic  processes  of  hands  and  feet,  to- 
gether with  minor  surgical  injuries;  and  a  large  proportion 
of  the  diseases  and  defects  of  special  organs,  particularly 
the  throat,  nose,  ears,  eyes  and  teeth.  New  demands  have 
come  upon  the  Dispensary  because  of  the  growing,  sense  that 
''minor "  diseases  are  important.  Medical  school  inspection 
and  industrial  medicine  are  adding  more  to  this  demand  than 
any  other  factors.  When  medical  school  inspection  is  car- 
ried out  to  the  extent  which  now  obtains  in  a  number  of 
cities,  almost  the  entire  population  between  the  ages  of  six 
and  fourteen  years  receive  periodical  medical  examinations, 
and  an  enormous  number  of  defects,  as  well  as  functional 
diseases,  are  revealed.  Questionable  eyesight,  bad  teeth, 
defective  hearing,  enlarged  tonsils,  occluded  nasal  passages, 
postural  defects  or  malformations  are  found  to  be  wide- 
spread. 

The  community  at  once  realizes  that  it  is  of  little  value  to 
spend  money  in  discovering  such  defects  unless  it  is  pre- 
pared to  remedy  them  after  they  are  found.  In  every  city 
where  medical  school  inspection  has  raised  this  problem, 
private  medical  practice  has  proved  itself  incapable  of 
solving  it. 


32  DISPENSARIES 

The  rapid  growth  of  Dispensaries  in  connection 
with  medical  work  in  industry  is  based  upon  the  medi- 
cal importance  of  the  Dispensary  field,  as  just  de- 
scribed, and  the  economic  value  of  restoring  a  worker 
as  promptly  as  possible  to  health  and  of  keeping  him 
well. 

3.  Classification  of  Dispensaries 

With  relation  to  their  medical  scope,  Dispensaries 
fall  into  two  obvious  types.  Some  are  for  the  treat- 
ment of  diseases  without  limitation,  although  such 
contagious  diseases  as  diphtheria,  scarlet  fever,  mea- 
sles, smallpox  and  whooping-cough  are  ordinarily 
excluded.  On  the  other  hand,  we  have  Dispensaries 
which  confine  themselves  to  a  single  disease  or  to  a 
group  of  closely  related  diseases,  such  as  the  tubercu- 
losis Dispensaries,  the  ^^eye  and  ear  infirmaries,"  the 
dental  or  the  psychiatric  Dispensary.  We  may  call 
the  one  group  the  general,  the  other,  the  special 
Dispensaries. 

This  distinction  involves  also  one  of  medical  organ- 
ization.  In  the  general  Dispensary,  of  large  size,  many 
specialists  are  at  work  together.  In  the  special 
Dispensary  there  may  be  only  a  single  specialty 
represented.  Does  such  an  institution  correspond 
with  our  definition  of  a  Dispensary,  in  which  there  is 
organization  of  equipment  and  organization  of  skill, 
among  a  group  of  physicians?  The  best  types  of 
special  Dispensaries  do  organize  equipment  and  skill 
by  properly  relating  the  institution  to  general  Dis- 
pensaries which   can  supply  the  needed   diagnostic 


SCOPE  AND   EXTENT  33 

advice,  or  treatment  in  certain  cases;  and  also  by 
enlisting  the  services  of  specialties  closely  related  to 
their  main  line.  Thus  a  tuberculosis  Dispensary  will 
make  arrangements  with  another  institution  so  that 
X-rays  can  be  obtained,  and  will  include  in  its  staff 
a  throat  specialist.  The  difficulty  of  doing  this, 
particularly  in  the  case  of  a  small  local  clinic,  is  often 
considerable,  and  offers  a  serious  limitation  to  the 
efficiency  of  special  Dispensaries.  An  eye  and  ear 
clinic,  for  example,  is  likely  to  overlook  general  condi- 
tions, even  when  connected  with  the  local  trouble, 
which  would  be  found  and  treated  at  a  general 
Dispensary.  Later,  we  shall  see  reason  to  believe  that 
the  specialized  Dispensary  along  most  lines  of  medical 
work,  is  a  mistake;  that  the  only  desirable  field  for 
the  special  Dispensary  is  in  localized  clinics  laying 
especial  emphasis  upon  preventive  work,  and  that 
these  are  most  efficient  when  they  are  grouped  to- 
gether, as  a  Health  Center. 

In  small  communities,  or  in  isolated  sections  of 
cities,  one  finds  small  general  Dispensaries,  with  a 
single  physician  holding  a  clinic  at  stated  periods. 
Such  are  not  infrequently  established  in  social  settle- 
ment houses.  The  value  of  such  clinics  must  be 
judged  in  comparison  with  the  other  local  medical 
facilities  available  to  the  people,  and  from  this  stand- 
point, little  Dispensaries  of  this  type  are  often  of  great 
service  to  a  neighborhood.  It  will  generally  be  found, 
however,  that  need  for  various  additional  special 
clinics  exists  and  is  in  fact  often  recognized;  and  that 
in  so  far  as  the  means  of  the  organization  permit,  it 


34  DISPENSARIES 

should  relate  itself  to  larger  institutions  so  as  to  secure 
X-rays  and  other  advantages,  and  should  have  certain 
locally  needed  specialties  represented  in  its  clinics 
(particularly  the  pediatric,  opthalmological,  laryngo- 
logical  and  dental).  The  proper  policy  for  such  Dis- 
pensaries is  discussed  in  Chapter  XVIII. 

A  second  distinction  of  much  practical  importance 
is  between  the  Dispensaries  connected  with  hospitals 
and  those  which  are  independent  of  hospitals.  The 
former  may  best  be  called  the  Out-Patient  Depart- 
ments* while  the  Dispensaries  which  are  not  connected 
with  hospitals  will  be  called  in  this  book  Out-Patient 
Institutions.  The  term  Dispensary  will  be  employed 
to  denote  any  medical  organization  treating  ambula- 
tory cases. 

While  all  Dispensaries  have  a  responsibility  for 
preventing  as  well  as  for  treating  disease,  we  may  make 
a  distinction  between  the  traditional  Dispensary 
which  receives  the  sick,  and  the  Public  Health  Dis- 
pensary whose  efforts  are  confined  wholly  or  largely 
to  prophylactic  work.  A  type  of  the  latter  is  the 
Well-Baby  Clinic.  The  Tuberculosis  Dispensary,  or  a 
Health  Center,  occupies  a  middle  ground,  with  the 
emphasis  usually  on  the  prophylactic  side. 

A    tendency    has    arisen,    particularly    in    Public 

* '^ Out-Patient  Department"  has  sometimes,  though  rarely,  been 
used  to  mean  patients  treated  in  their  homes.  The  term  Out-Patient 
Department,  however,  has  now  come  to  be  much  more  generally 
employed  to  mean  a  Dispensary  attached  to  a  hospital  and  will  be 
used  in  this  sense  in  this  book.  When  a  hospital  gives  medical  treat- 
ment to  persons  in  their  homes,  this  division  of  the  institution's  work 
may  best  be  called  the  Home  Patient  Department. 


SCOPE  AND  EXTENT  35 

Health  Dispensaries,  to  limit  the  patients  received  to  a 
definite  area  around  the  Dispensary.  The  traditional 
Dispensary  receives  patients  without  restriction  as  to 
residence.  For  certain  purposes  it  will  be  convenient 
to  refer  to  a  Dispensary  serving  a  defined  area  as  a 
District   Dispensary. 

We  shall  also  have  occasion  to  refer  to  the  Teaching 
Dispensary,  meaning  one  in  which  the  instruction  of 
medical  students  is  carried  on.  Such  Dispensaries 
include  those  which  are  under  the  direct  control  of 
medical  schools  and  also  those  in  which  there  is  merely 
a  school  affiliation. 

A  graphic  summary  of  these  distinctions  may  be 
found  convenient : — 

Classification  of  Dispensakies 

I.  As  to  Medical  Scope: 

General  (treating  all  diseases) 

Special  (confined  to  one  or  a  few  specialties) 

II.  As  to  Relation  with  Other  Medical  Institutions: 
Out-Patient  Departments  (of  hospitals) 
a.  <  Out-Patient  Institutions  (separate  from  a  hos- 
pital) 
f  Teaching  (medical  students) 
'  \  Non-teaching 

III.  As  to  Public  Function: 

r  Clinical  medicine  primarily 
a.  \  Prophylactic  work  primarily  (Public  Health  Dis- 
[      pensary) 

J  District  Dispensary  (serving  a  definite  area) 
*  \  Dispensary  unrestricted  as  to  area 


36 


DISPENSARIES 


4.  Number  and  Location  of  Dispensaries  in  the  United 

States 

Early  in  1916,  the  Committee  on  Dispensary  Work 
of  the  American  Hospital  Association,  of  which  one  of 
the  authors  was  Chairman,  undertook  a  post-card 
census  of  Dispensaries.  The  following  table,  quoted 
from  the  Committee's  Report, ^^  summarizes  the  find- 
ings: 

DISPENSARIES  IN  THE  UNITED  STATES.   1916 


Known 

Addi- 
tions 
Esti- 
mated 

Total 

I,     Treating  General  Diseases. — 

Out-Patient    Departments    of 

hospitals . 

Dispensaries  unconnected  with 

hospitals 

495 
185 

150 
70 

645 
255 

Total 

II.     Treating  Special  Diseases 

III.     Public  Health  Dispensaries. — 

Tuberculosis 

Baby  Hygiene 

School  Children 

680 

60 

In  1904 

20 

0 

0 

0 

220 
40 

900 
100 
In  1916 
500 
400 
250 

Psychiatric,  Dental,  etc 

150 

Total 

20 

1,300 

Summary  : — 

General  Dispensaries  and  Out-Patient  Depts. 
Special  Dispensaries  and  Out-Patient  Depts. 
Public  Health  Dispensaries 


900 

100 

1,300 


Grand  Total. 


2,300 


The  table  suggests  the  remarkable  recent  growth  of 
Dispensaries.  Practicall}^  all  the  public  health  Dis- 
pensaries are  products  of  the  decade  preceding  1916. 
As  for  the  other  Dispensaries,  in  1800  there  were 


SCOPE  AND   EXTENT  37 

"three  out-patient  departments  and  Dispensaries  in  the 
United  States;  in  1904  (when  the  United  States  Census  made 
a  survey),  there  were  only  150  general  Dispensaries;  in  1910, 
when  the  Census  made  a  second  survey,  there  were  450;  in 
1916,  we  know  of  700,  and  undoubtedly  there  are  at  least 
200  more  institutions  which  did  not  send  the  post  cards 
back.'' 

The  ^^  additions  estimated '^  for  this  reason,  may  be 
regarded  as  conservative.  It  is  of  interest  to  observe 
that  nearly  one  third  of  the  2,000  odd  hospitals  in  the 
United  States  which  may  be  rated  as  ^' public,^'  had 
out-patient  departments  in  1916.  This  is  more  than 
double  the  percentage  which  prevailed  in  1904,  when 
the  Census  made  its  first  survey.  Of  course  the  many 
private  hospitals  and  the  sanitoriums  for  convalescent 
cases,  rarely  have  out-patient  departments.  No  data 
existed  in  1916,  for  making  more  than  a  guess  at  the 
number  of  Industrial  Dispensaries,  and  the  table  is 
undoubtedly  seriously  deficient  in  this  respect.  Their 
number  has  been  increasing,  during  the  last  two  or 
three  years,  more  rapidly  than  any  other  type  of 
Dispensary,  even  the  Public  Health  Dispensaries. 
Until  a  national  survey  of  Health  work  in  industry  is 
made,  sufficient  to  bring  out  the  existence  of  all  these 
Dispensaries,  estimates  of  their  number  must  remain 
mere  guess-work.  The  guess  may  be  hazarded  that 
by  the  close  of  1917  there  were  betw^een  300  and  500 
Industrial  Dispensaries  in  the  United  States,  and  that 
the  total  number  of  Dispensaries  of  all  classes  is  ap- 
proximately 3,000. 

Another  table,  showing  the  location  of  the  Dispen- 


38  DISPENSARIES 

saries  of  the  country,  may  be  quoted  from  the  same 
Committee   Report. 

"Location  of  680  General  Dispensaries  listed  in  1916,  by 
the  Committee  on  Dispensary  Work,  American  Hospital 
Association — 

State  Number 

New  York 145 

Pennsylvania 123 

Massachusetts 67 

Illinois 45 

New  Jersey 40 

Ohio 30 

Missouri 29 

Maryland 24 

District  of  Columbia 17 

Michigan 17 

Connecticut 16 

Minneapolis 11 

Virginia 10 

Rhode  Island 9 

Wisconsin 8 

Twenty-Six  Other  States 89 

Total  listed  in  United  States 680 

In  1900,  New  York,  Pennsylvania  and  Massachusetts 
contained  about  sixty  per  cent  of  all  the  Dispensaries  of  the 
United  States;  in  1916  they  had  only  forty  per  cent.'* 

These  figures  well  illustrate  the  historical  develop- 
ment of  Dispensaries  which  we  have  traced  in  the 
preceding  chapter.  The  concentration  of  institutions 
in  the  large  eastern  cities  has  been  due  to  the  fact  that 
all  forms  of  charitable  work  have  been  relatively  ad- 
vanced therein  and  also  because  each  of  these  communi- 
ties is  a  centre  of  medical  education  with  one,  or  more 
than  one,  medical  college.  Examination  of  a  map 
would  show  that  in  1900  the  Dispensaries  in  the 
United  States  outside  of  the  Atlantic  seaboard  we^^ 


SCOPE  AND   EXTENT  39 

chiefly  located  in  cities  where  a  medical  school  existed. 
Development  in  recent  years  has  made  this  no  longer 
true,  for  the  realization  by  hospitals  that  an  out- 
patient department  is  of  value  in  following  discharged 
cases  and  also  in  serving  the  community  as  a  whole, 
has  led  many  institutions,  feven  hospitals  of  small  size 
and  in  small  cities,  to  start  out-patient  departments. 
The  number  of  medical  schools  has  diminished  nearly 
fifty  per  cent  during  the  same  period  wherein  general 
Dispensaries  have  increased  more  than  one  hundred 
per  cent.  __ 

A  different  set  of  forces  has  been  at  work  in  connec- 
tion with  the  public  health  Dispensaries.  Their 
remarkable  recent  growth  has  had  little  connection 
with  medical  schools.  These  Dispensaries  have  also 
been  started  in  large  cities,  but  by  state  law  in  some 
cases  and  private  initiative  in  many  others,  have  been 
scattered  throughout  towns  and  small  cities  for  the 
sake  of  the  babies,  the  school  children,  or  the  tubercu- 
losis cases.  The  location  of  the  industrial  Dispensaries 
has  of  course  been  determined  more  by  business  con- 
siderations than  by  medical  or  charitable  ones. 

The  statistical  reports  of  some  Dispensaries  are 
unpublished,  of  many  are  inaccessible;  and  it  is  im- 
possible to  state  accurately  the  number  of  patients 
annually  treated  by  Dispensaries  in  the  United  States. 
Estimating  from  trustworthy  reports  of  Dispensaries 
in  New  York,  Boston,  and  other  cities,  it  is  probable 
that  the  Dispensaries  of  the  country  are  recei\dng  an- 
nually between  twelve  and  fifteen  million  visits  from 
between  four  and  five  million  individual  patients. 


40  DISPENSARIES 

The  size  of  particular  institutions  ranges  over  the 
widest  Umits.  At  one  extreme  are  enormous  Dispen- 
saries Uke  that  of  the  Mt.  Sinai  Hospital  in  New  York, 
receiving  nearly  a  quarter  of  a  million  visits  in  a  year; 
at  the  other  are  little  Public  Health  Dispensaries 
receiving  a  thousand  visits.  The  Committee  on 
Dispensary  Work  of  the  American  Hospital  Associa- 
tion tabulated  the  Reports  of  148  Dispensaries  in 
1914,  classifying  them  as  to  size,  and  showing  the 
following : — 

Receiving  over  100,000  visits  a  year . 9 

Receiving  60,000  to  100,000  a  year 14 

Receiving  30,000  to  60,000  visits  a  year 18 

Receiving  10,000  to  30,000  visits  a  year 44 

Receiving  2,500  to  10,000  visits  a  year 43 

Receiving  less  than  2,500  a  year 20 

148 

The  Public  Health  Dispensaries  would  mostly  fall 
into  the  last  two  classes. 

These  studies  of  the  nature,  history,  present  types 
and  locations  of  Dispensaries  in  the  United  States  will 
serve  as  a  useful  preliminary  to  this  volume. 

QUESTIONS  AHEAD 

What  are  the  fundamental  principles  of  the  organ- 
ization and  management  of  a  Dispensary,  and  of  its 
relationship  to  the  community?  What  groups  or 
*' social  classes''  of  patients  do  Dispensaries  serve? 
What  classes  should  they  serve?  How  shall  the  func- 
tions of  the  physician,  the  nurse,  the  social  worker,  and 
the  administrative  officer,  be  inter-related  so  as  to 
make  an  efficient  institution? 


SCOPE  AND  EXTENT  41 

Some  of  these  questions  lead  us  from  general 
principles  into  the  practical  technique  of  arrangement 
of  rooms,  medical  and  surgical  equipment,  records, 
follow-up  systems,  statistics,  and  finance.  The  small 
Dispensaries,  as  well  as  the  large  ones,  must  have  at- 
tention and  special  needs  of  different  types  of  Dispen- 
saries must  be  described.  Last,  but  far  from  least, 
arise  the  broad  public  problems  which  dispensary  work 
is  now  placing  before  the  medical  profession  and  the 
public.  What  part  are  Dispensaries  to  play  in  provid- 
ing medical  service  to  the  people  in  the  future?  What 
is  to  be  their  place  in  public  health  work,  in  social 
service,  in  industry?  Conflicting  tendencies  appear 
in  this  field,  between  the  fine  tradition  of  the  family 
physician  and  the  growing  dominance  of  the  speciaUsts ; 
between  the  desire  for  individual  relationship  between 
patient  and  doctor  and  the  increasing  efficiency  of 
institutional  medicine;  between  uncertain  support 
from  private  funds  and  support  by  taxation  with 
political  representation  upon  the  managing  board; 
between  enlarging  social  service  and  rising  objection 
to  ^'charity." — Among  such  alternatives  what  future 
shall  come  forth? 


42  DISPENSARIES 


CHAPTER   IV 
WHO   ARE   DISPENSARY  PATIENTS? 

Over  four  million  men,  women  and  children  are 
receiving  treatment  annually  at  the  Dispensaries  of 
the  United  States.  One  might  imagine  that  the 
Dispensaries  could  report  fully  the  economic  and  social 
groups  from  which  this  vast  number  are  drawn.  But  if 
one  examines  Annual  Reports  or  articles  about  Dispen- 
saries, one  finds  that  the  chief  subject  of  discussion 
has  not  been  '^  Who  are  the  people  that  we  are  treating; 
what  are  their  needs,  and  how  shall  they  be  treated 
most  efficiently?"  but  instead  ''How  shall  we  keep 
people  from  getting  treatment?"  '  'Dispensary  abuse," 
by  persons  able  to  pay  private  physicians,  has  been 
talked  about  in  this  country  for  over  thirty  years. 
The  study  of  dispensary  eflSciency  and  of  the  social 
and  economic  classes  coming  to  Dispensaries  comprises 
as  yet  only  a  fraction  of  the  literature  on  the  subject. 

The  rapid  growth  of  Dispensaries  in  some  eastern 
cities,  particularly  in  New  York,  during  the  latter  part 
of  the  nineteenth  century,  naturally  caused  consider- 
able discussion  among  the  medical  profession,  and  many 
articles  varying  in  their  premises  and  in  their  argu- 
ments appeared.  "A  Propagator  of  Pauperism:  the 
Dispensary"  was  the  title  of  an  article  by  Dr.  George 
F.  Shrady,  published  in  1897  in  The  Forum.^^  ^^t 
may  be  broadly  stated,"  says   the  article,  "as  the 


DISPENSARY  PATIENTS  43 

result  of  exhaustive  statistical  study,  that  fully  fifty 
per  cent  of  the  patients  who  apply  for  free  medical 
aid  are  totally  undeserving  of  such  charity.  ...  In 
New  York  City  alone  there  are  116  Dispensaries,  each 
of  which  is  vying  with  the  others  in  propagating  the 
worst  form  of  pauperism." 

As  an  example  of  another  view,  we  may  quote  from  a 
paper^3  ^y  j)^^  ^^  g^  Thayer  in  which  he  cites  with 
general  approval  an  '^ eminent  physician,"  unnamed, 
as   follows : 

"'My  views  on  dispensary  abuse  have  never  been  win- 
nowed and  tried  out  by  careful  investigation  of  the  subject, 
but  so  far  I  think  the  chief  dispensary  abuses  are:  (1)  The 
abuse  of  patients  by  careless  doctors  and  internes.  (2)  The 
abuse  of  opportunities  by  careless  doctors  and  internes. 
That  any  great  harm  comes  from  treatment  of  the  folk  who 
can  pay,  I  doubt.  ...  I  think  it  more  than  made  good, 
from  the  point  of  view  of  the  public  good,  which  is  the  only 
point  of  view  that  we  can  take,  by  the  physical,  psychical 
and  educational  good  done  by  the  Dispensary,  even  for  rich 
patients.  I  do  not  believe  you  can  surely  weed  out  the  rich, 
either,  by  any  spotting  process.'" 

It  was  but  slowly  that  the  discussion  of  ' '  dispensary 
abuse"  led  to  constructive  efforts.  What  was  really 
needed  were  facts  instead  of  opinions — facts  of  the 
actual  social  or  financial  conditions  of  dispensary 
patients.  At  the  International  Conference  of  Chari- 
ties, Correction,  and  Philanthropy,  1893,  in  the  Sec- 
tion on  ^'Hospitals,  Dispensaries  and  Nursing,"  Mr. 
Charles  C.  Savage  reviewed  the  history  of  Dispensa- 
ries, ^^  and  stated  that  one-quarter  of  the  population  of 


44  DISPENSARIES 

New  York  City  were  receiving  dispensary  aid  (present 
statistics  do  not  indicate  such  a  proportion).  Mr. 
Savage  based  this  statement  on  an  investigation  which 
he  declared  had  been  conducted  by  the  New  York 
Charity  Organization  Society.  From  the  ninth  an- 
nual report  of  this  organization  (page  26)  it  appears 
that,  in  1884, 

''this  society  undertook  to  examine  for  the  German  Dis- 
pensary, the  ability  to  pay  for  treatment  of  such  of  its  ap- 
plicants as  were  referred  to  us,  with  the  following  result: 
forty-three  per  cent  were  found  able  to  pay,  twenty-seven 
per  cent  were  found  unable  to  pay,  thirty-per  cent  gave  false 
or  mistaken  addresses." 

''Each  year  as  it  became  more  widely  known  that  the 
Dispensary  availed  itself  of  our  investigations,  applications 
from  those  who  could  well  afford  to  pay  for  advice  and  treat- 
ment diminished,  until  in  1889  the  following  very  different 
results  were  reached :  Those  able  to  pay  declined  from  forty- 
three  to  twenty-three  per  cent.  Those  giving  false  addresses 
or  other  evidence  of  deceit  fell  from  thirty  to  twenty-five, 
and  correspondingly,  those  entitled  to  the  benefits  of  the 
Dispensary,  after  thus  sifting  out  the  imposters,  increased 
from  twenty-seven  to  fifty-two  per  cent." 

Inasmuch  as  the  Charity  Organization  Society  did 
not  investigate  all  the  applicants  at  the  German 
Dispensary,  but  only  such  cases  as  were  referred  to  it 
— which  unquestionably  were  the  doubtful  cases — we 
can  in  no  way  estimate  the  real  meaning  of  the  figures 
which  they  reported.  As  will  be  seen,  an  investiga- 
tion of  one  thousand  cases  conducted  in  1910-11  led 
to  an  entirely  different  conclusion. 


DISPENSARY  PATIENTS  45 

Dr.  Shrady's  attack,  already  quoted,  was  by  no 
means  the  first  of  its  kind,*  and  did  not  find  the  Dis- 
pensaries without  defenders.  1^  The  rapid  growth  of 
these  institutions  in  the  metropoUs,  however,  led  to 
considerable  agitation,  with  the  result  that  the  well- 
known  law  licensing  Dispensaries  throughout  New 
York  State  and  placing  them  under  the  general  super- 
vision of  the  State  Board  of  Charities  was  enacted 
in  1899.  The  regulations  made  under  this  legislation 
require  certain  items  to  be  annually  reported,  records 
kept,  and  a  registrar  on  duty  at  every  Dispensary — 
these  being  highly  valuable  features  of  the  law. 
Applicants  whose  '^personal  appearance"  does  not 
indicate  that  they  are  ^ indigent''  may  be  required 
to  sign  a  form,  attesting  their  income,  etc.  The 
penalty  for  false  representation  is  printed  upon  the 
admission  card  given  to  every  patient.  No  violations 
of  this  appear  to  have  been  prosecuted  during  the 
fifteen  years  since  the  enactment  of  the  law. 

In  1903  the  Hospital  Association  of  Philadelphia 
caused  an  investigation  of  dispensary  patients  to  be 
made,  but  we  have  not  been  able  to  obtain  a  copy  of 
the  report.  In  1905  a  symposium  on  the  subject  was 
published  in  the  Boston  Medical  and  Surgical  Journal.^^ 
Dr.  George  W.  Gay  sent  out  at  this  time  a  question- 
naire to  more  than  four  hundred  physicians  in  Boston 

*  Dr.  Gurteen,  one  of  the  pioneers  in  the  charity  organization  move- 
ment in  the  United  States,  in  his  well-known  "Handbook  of  Charity 
Organization"  (1882),  described  the  dispensary  system  as  a  ''vast 
school  of  pauperism,  demoraUzing  the  poor,  educating  them  in  im- 
provident habits,  and  teaching  them,  in  one  of  the  most  vital  depart- 
ments of  life,  to  be  thriftless  and  improvident"  (page  99). 


46  DISPENSARIES 

and  vicinity.  A  large  majority  of  the  three  hundred 
odd  answers  which  were  received  stated  that,  in  the 
opinion  of  the  physicians,  medical  charity  was  abused 
in  the  hospitals  and  Dispensaries  in  Boston,  and  that 
it  was  practicable  to  correct  it.  Such  a  question- 
naire, of  course,  collected  only  opinions  and  furnished 
no  facts  regarding  the  extent  or  character  of  abuse, 
nor  many  concrete  suggestions  how  corrections  should 
be  made. 

In  1907  the  Chicago  Medical  Society  appointed  a 
^'Committee  on  the  Abuse  of  Medical  Charities," 
which  secured  co-operation  from  the  Associated 
Charities  of  Chicago,  and  presented  a  report.^ ^  This 
indicated  that,  out  of  fifty-five  Dispensaries  said  to  be 
treating  approximately  500,000  patients  a  year,  only 
three  instituted  any  ''adequate  investigation  into  the 
economic  capability  of  their  patients."  The  Com- 
mittee of  the  Medical  Society,  however,  made  no  study 
of  ''economic  capability"  on  its  own  part. 

Dr.  W.  S.  Thayer  reported  in  the  same  year  (1907) 
the  results  of  an  investigation  by  a  committee  of  the 
Medical  and  Chirurgical  Faculty  of  Maryland.  This, 
like  Dr.  Gay's  reports,  was  based  on  consultation  with 
physicians.  The  Journal  of  the  American  Medical 
Association,  commenting  editorially  on  this  report, 
said:  "It  would  seem  to  be  more  to  the  point  if  an 
exact  tabulation  of  Baltimore  Dispensaries  had  been 
made." 

Such  a  tabulation  on  an  extended  scale  was  carried 
through  in  1910  by  the  Medical  Society  of  the  County  of 
New  York,  which  employed  Miss  Anna  Moore,  Ph.D., 


DISPENSARY  PATIENTS  47 

an  investigator  trained  in  the  work  of  the  New 
York  Charity  Organization  Society,  to  study  a  thou- 
sand cases  selected  at  random  from  the  books  of 
thirteen  Dispensaries  in  Manhattan.^^  Miss  Moore 
visited  the  homes  of  these  patients,  but  was  unable 
to  locate  two  hundred  and  twenty-five  out  of  the 
thousand.  The  tables  submitted  by  her  indicate 
that  of  the  seven  hundred  and  forty-five  patients  whom 
she  located  and  whose  financial  conditions  she  studied, 
six  hundred  and  seventy-two,  or  ninety  per  cent,  were 
^^  worthy  of  free  treatment. "  The  remaining  seventy- 
three,  or  approximately  ten  per  cent,  seemed : — 

''Able  to  pay  for  medical  treatment  under  ordinary  cir- 
cumstances. But  the  margin  over  and  above  fixed  ex- 
penditures seems  in  most  cases  so  slight  that  in  illness 
demanding  continued  treatment  or  the  services  of  a  special- 
ist, to  pay  a  physician  would  mean  for  them  serious  depriva- 
tion or  the  incurring  of  a  debt  from  which  afterwards  it 
would  be  difficult  to  escape.  In  fact,  in  almost  every  one  of 
these  cases,  there  seemed  a  very  reasonable  doubt  as  to  how 
the  case  should  be  regarded." 

Of  the  two  hundred  and  fifty-five  cases  which  could 
not  be  located  at  the  addresses  given.  Miss  Moore 
estimates  that  the  addresses  probably  were  given  in- 
correctly with  intent  to  deceive  in  thirty-two  cases,  or 
twelve  and  one-half  per  cent.  In  the  remainder,  the 
failure  to  find  the  patients  was  due  to  incorrect 
transcription  at  the  Dispensary  of  name  or  address 
(estimated  at  thirty-four  per  cent)  and  to  the  moving 
of  patients  or  families  between  the  time   their  ad- 


48  DISPENSARIES 

dress  was  recorded  at  the  Dispensary  and  the  time 
Miss  Moore's  visit  was  paid. 

At  the  Boston  Dispensary  studies  were  begun  in 
November,  1911,  and  pursued  thereafter,  covering 
up  to  1914  five  groups  of  patients,  1,881  in  all.  The 
primary  purpose  was,  of  course,  not  to  estimate  the 
amount  of  ^ 'abuse,''  but  to  ascertain  how  facts  as  to 
social  and  financial  conditions  of  patients  could  be 
obtained  most  accurately  and  economically,  and 
whether  standards  could  be  formulated  for  judging  the 
eligibility  of  patients  for  admission. 

The  conclusions  reached  by  the  Boston  Dispensary 
studies,^^  up  to  1914,  were  that  not  over  two  per  cent 
of  the  applicants  at  this  institution  could  have  paid 
for  the  medical  care  they  needed  at  private  rates.  A 
further  series  of  studies  made  during  1914  and  1915, 
may  be  summarized  as  follows: 

"A  tally  of  1,414  Boston  Dispensary  patients  showed: — 

"One  hundred  and  sixty-three,  or  llVio%  had  incomes, 
above  the  sum  assumed  by  us  to  be  necessary  before  any 
balance  large  enough  for  much  medical  service  is  found. 

"These  163  cases  were  then  studied  apart  and  the  at- 
tempt made  to  estimate  the  cost  of  private  treatment  for 
their  sickness.     As  a  result: 

"Sixty-three  (4J%)  could  have  paid  at  the  rate  of  our 
evening  pay  clinics,  and  were  in  many  instances  referred 
thereto : 

"Twenty-six  (lVio%)  could  probably  have  been  referred 
to  private  practice  after  diagnosis  had  been  established,  but 
could  not  have  paid  the  cost  of  making  the  diagnosis ; 

"Sixteen  (1J%)  were  judged  able  to  pay  at  private  rates 


DISPENSARY  PATIENTS  49 

for  the  treatment  required.  Such  judgment  must  remain  a 
matter  of  opinion  until  a  more  exact  measure  of  the  standard 
of  hving  in  a  given  locaHty  is  found  and  apphed." 

Dr.  Borden  S.  Veeder,  of  St.  Louis,  in  a  valuable 
paper^*^  came  to  about  the  same  conclusion  as  that 
reached  at  the  Boston  Dispensary  and  the  Presbyte- 
rian Hospital  at  Philadelphia,^!  namely,  that  at  the 
Washington  University  Dispensary  with  which  Dr. 
Veeder  is  connected,  not  over  two  per  cent  of  the 
patients  could  afford  private  medical  care.  Says  Dr. 
Veeder: 

''This  is  certainly  a  small  percentage  of  imposition,  and 
much  less,  I  imagine,  than  the  percentage  of  the  average 
physician's  patients  who  are  'bad  pay.'  The  cost  and  time 
involved  thoroughly  to  investigate  every  applicant  in  order 
to  eliminate  this  two  per  cent  is  not  worth  the  effort  or 
expense.  It  would  be  comparable  with  a  physician  making 
a  careful  financial  investigation  of  each  patient  in  order  to 
eliminate  two  per  cent  who  were  bad  pay." 

Thus  actual  facts  secured  concerning  dispensary 
clienteles  show  that  so  far  as  so-called  ''abuse"  is 
concerned,  it  is  in  percentages  a  negligible  factor. 
The  modern  Dispensary,  we  must  remember,  offers  a 
wide  range  of  medical  services,  from  care  for  minor 
general  diseases  to  highly  specialized  work  in  opthal- 
mology,  orthopedics,  X-ray,  etc.  A  large  proportion 
of  the  patients  at  Dispensaries  come  for  special  treat- 
ment, which  is  particularly  expensive  at  the  usual 
private  rates.  The  cost  of  the  equivalent  medical 
service,  did  they  receive  it  privately,  cannot  therefore 


50  DISPENSARIES 

be  estimated  merely  on  the  basis  of  the  cost  per  visit 
to  a  general  practitioner. 

The  studies  of  dispensary  patients  above  referred  to 
have  usually  begun  with  a  crude  attempt  to  say  what 
patients  are  eligible  for  medical  treatment,  without 
defining  what  ''eligibility"  is.  The  later  studies, 
particularly  those  of  Dr.  Veeder  and  those  of  the 
Boston  Dispensary,  have  endeavored  to  establish 
certain  standards,  and  to  consider  the  patient  with 
reference  to  needs  as  well  as  to  resources.  Dr. 
Veeder  for  example  reviews  a  series  of  studies  on  the 
cost  of  living,  made  by  governmental  and  private 
bureaus  at  various  times  in  this  country.  He  then 
formulates  certain  standards  applicable  in  his  own 
community,  specifying  income  limits,  below  which 
free  dispensary  treatment  may  be  regarded  as  suitable. 
On  the  question  of  cost  of  treatment,  however,  he 
points  out  the  wide  variations  and  comes  to  the  con- 
clusion that,  owing  to  the  complexity  of  the  factors 
involved,  each  individual  case  must  be  settled  on  its 
own  merits. 

In  the  studies  made  at  the  Boston  Dispensary,  these 
elements  of  cost  of  service  have  been  more  emphasized. 
Miss  Janet  Thornton,  Registrar  of  the  Boston  Dis- 
pensary, writing  in  1915,  made  the  following  sum- 
mary :22 — 

''The  factors  that  seem  fundamental  may  be  grouped  un- 
der two  headings;  which  together  constitute  a  general 
standard  by  which  each  particular  case  can  be  measured. 


DISPENSARY     PATIENTS  5| 

I.  Income  and  Expenditure 

"a.  What  is  the  wage  scale  in  the  trades  and  industries  of 
the  community? 

''b.  At  what  point  in  the  scale  is  there  a  theoretical 
margin  above  subsistence,  or  more  explicitly,  what  does  it 
cost  in  the  community  to  get  food  and  fuel,  clothes,  and 
shelter  sufficient  to  maintain  well-being  and  a  modicum  of 
leisure  and  enjoyment  (for  lacking  these  basal  necessities  the 
finest  medical  service  is  all  but  wasted)  ? 

2.  Medical  Need 

''a.  What  average  amount  of  medical  care  is  required  in  a 
year  to  keep  an  individual  or  a  family  in  health  and  working 
trim? 

"b.  What  does  it  cost  in  the  community  to  obtain  ade- 
quate treatment  for  common  ailments? 

^'Medical  institutions  have  the  knowledge  to  answer 
accurately  the  questions  under  the  second  heading.  Within 
themselves  they  have  no  reliable  means  to  answer  fully  those 
under  the  first,  but  must  turn  to  scientists  who  in  work-shop, 
laboratory  and  household  are  now  studying  wages,  food  and 
domestic  conditions.  It  does  not  seem  too  much  to  hope 
that  they  can  soon  give  us  knowledge  on  which  to  base  at 
least  a  minimum  requirement  for  the  necessities  of  life, — 
food,  shelter,  etc.  Meanwhile  it  will  be  helpful  to  clarify 
our  own  minds  as  to  what  standards  we  are  using.  A  good 
deal  of  study  has  been  given  to  the  subject  at  the  Boston 
Dispensary,  and  a  brief  statement  of  our  conclusions  may  be 
worth  attention,  in  spite  of  the  incompleteness  of  certain 
aspects. 

''In  the  last  four  years  not  fewer  than  75,000  applicants 
to  the  Dispensary  have  been  asked  most  or  all  of  the  ques- 


52  DISPENSARIES 

tions  on  the  registration  card.  Even  allowing  for  error  and 
misstatement  there  must  remain  from  so  many  replies  a 
reliable  picture  in  rough  design  of  the  social  and  financial 
state  of  these  patients.  The  tables  prepared  help  to  define 
at  least  the  financial  phase  of  the  admission  problem  and  to 
warrant  the  following  averages: — 

''Fully  three-quarters  of  all  our  patients  belong  to  family 
groups,  and  more  than  three-fourths  of  these  families  have 
but  one  wage-earner.  Thirty-seven  per  cent  of  families 
live  on  $600,  or  less,  forty  per  cent  on  $700,  or  less,  seventy 
per  cent  on  $800,  or  less,  seventy-seven  per  cent  on  $900,  or 
less,  eighty-three  per  cent  on  $1,000  or  less  per  annum;  three 
per  cent  are  dependent  on  charitable  relief;  fourteen  per  cent 
have  over  $1,000,  i.e.,  not  more  than  1,400  new  families  a 
year  have  more  than  $1,000,  while  8,000-9,000  have  less 
than  $1,000.*  Among  those  listed  as  unmarried,  there  are 
about  4,000  new  patients  a  year;  of  whom  78.6  per  cent 
are  living  on  $600  or  less  a  year,  i.e.,  only  between  700-800 
unmarried  applicants  out  of  4,000  earn  over  $12  a  week. 

''It  is  a  general  opinion  among  students  of  wage-earners' 
budgets  that  even  small  families  in  this  vicinity  living  on 
$1,000  or  less  a  year  should  not  be  expected  to  purchase 
more  medical  service  than  that  necessary  to  childbirth  and 
acute  illness  in  the  home.  As  the  use  of  our  free  District 
Physicians  shows,  many  families  cannot  meet  even  these 
emergencies.  We  have  seldom,  therefore,  doubted  eligibil- 
ity or  refused  treatment  at  this  Dispensary,  unless  the  family 

*  "These  estimates  include  all  the  earnings  of  working  children.  If 
the  income  of  the  chief  wage-earner  (in  most  cases  the  father)  is  taken, 
the  number  having  over  $1,000  is  reduced  3.5  per  cent,  while  ninety- 
two  per  cent  have  $1,000  or  less.  The  wages  of  children  as  a  rule 
amount  to  little  more  than  enough  to  keep  them  in  condition  to  fill 
their  positions.  Also,  though  the  incomes  are  based  on  average  wages, 
no  careful  attempt  is  made  to  estimate  unemployment." 


DISPENSARY  PATIENTS 


53 


income  exceeded  $1,000.  Our  rule  for  the  unmarried  wage- 
earner  is  to  weigh  carefully  the  reason  for  accepting  when  the 
income  passes  $600." 

Miss  Thornton  further  points  out  that,  owing  to  the 
widely  varying  cost  of  medical  service,  the  fact  that  a 
family  is  above  the  income  limit  just  noted  merely 
raises  the  question  of  eligibility  but  does  not  answer  it. 

Important  evidence  of  the  social  groups  from  which 
dispensary  patients  are  drawn  has  been  furnished  by 
two  Commissions  appointed  by  State  Legislatures  to 
study  Health  Insurance.  The  Social  Insurance  Com- 
mission of  California,  with  Dr.  I.  M.  Rubinow  as  their 
consulting  actuary,  investigated  the  Dispensaries  of 
San  Francisco  and  Los  Angeles  in  1916.23  Since  the 
conclusions  concerning  the  two  cities  were  practically 
identical,  only  those  from  San  Francisco  need  be 
quoted.  In  the  following  table  these  are  compared 
with  a  study  undertaken  by  one  of  the  writers  in  1917 
at  the  request  of  the  Social  Insurance  Commission  of 
Massachusetts.^^ 


Social  Group 

San  Francisco 

Boston 
Boston  Dispensary 

No. 

Per  cent 

No. 

Per  cent 

Incomes  under  $14  weekly  .  . 

Incomes  $14  to  $20 

Incomes  over  $20 

1,098 
581 
380 

528 

22^ 
201 

444 

547 

170 

35 

37.1 

45.7 
14  2 

Unspecified  or  miscellaneous 

3.0 

Total 

2,587 

100 

1,196 

100 

Dependent  on  Charity 

190 

7 

35 

3 

54  DISPENSARIES 

The  incomes  given  in  this  table  are  family  incomes, 
including  the  estimated  total  of  earnings  of  all  gain- 
fully employed  persons  in  the  family.  There  is  a 
very  striking  agreement  between  the  two  studies, 
independently  made,  at  the  two  extremes  of  the  con- 
tinent. Both  indicate  that  the  great  bulk  of  dis- 
pensary patients  are  wage-earning  families  of  in- 
comes sufficient  to  meet  their  ordinary  expenses,  but 
not  to  provide  for  adequate  medical  service.  The 
incomes  of  these  families  are  not  below  those  usual 
among  the  wage-earning  families  in  American  com- 
munities. 

Since  the  general  wage  statistics  of  this  country  in- 
dicate that  not  more  than  one  wage-earner  in  ten  has 
an  annual  income  of  over  $1,000,  it  is  obvious  that  a 
large  majority  of  the  families  cannot  afford  to  pay  for 
complete  medical  service.  The  growing  recognition  of 
the  importance  of  adequate  medical  care  as  an  element 
in  industrial  and  national  efficiency  is  thus  forcing  into 
the  foreground  the  need  of  supplementing  the  ordinary 
resources  of  private  medical  practice  by  forms  of 
organized  medical  service.  Dispensaries  are  one  an- 
swer to  this  demand. 

The  practical  question  may  now  be  raised:  What 
have  Dispensaries  done  and  what  are  Dispensaries 
doing  to  deal  with  the  varying  elements  in  their  clien- 
tele or  the  applicants  for  admission  to  their  clientele? 

In  reorganizing  the  Dispensary  of  Lakeside  Hospital 
and  Western  Reserve  University  in  1911,  one  of  the 
writers  attempted  to  deal  with  the  problem  by  classify- 
ing the  patients  into  certain  roughly  separated  but 


DISPENSARY  PATIENTS  65 

important  divisions  as  follows:  (a)  Suitable  for  ad- 
mission for  treatment  in  any  department  until  ad- 
mission is  revoked,  (b)  Suitable  for  admission  in  any 
department  for  the  current  sickness  only,  any  other 
sickness  requiring  another  interview  with  the  admit- 
ting officer,  (c)  Suitable  for  admission  for  major  or 
special  surgery,  or  for  any  chronic  condition  for  which 
the  patient  cannot  be  expected  to  pay  the  ordinary  fees 
for  the  treatment  needed,  (d)  Suitable  for  admission 
for  special  examination  or  consultation  only  (e.g., 
X-ray,  Wassermann)  no  treatment  being  given.^^ 

In  1913  a  questionnaire,  sent  out  under  the  auspices 
of  the  American  Hospital  Association,  included  the 
following  inquiries  on  the  subject  of  dispensary  abuse:" 

''  What  is  your  system  of  investigation  of  each  new  patient 
to  prevent  abuse  of  medical  charity?  What  is  your  stand- 
ard of  exclusions,  i.e.,  what  classes  of  patients  are  in  practice 
excluded?  How  many  patients  of  the  total  number  apply- 
ing for  treatment  were  thus  excluded  last  year?" 

''Of  seventy-six  institutions,  mostly  very  representative 
ones,  which  responded  to  this  questionnaire,  only  thirty-six 
stated  that  any  applicants  had  been  excluded.  Some  of  the 
remaining  forty  may  have  forgotten  to  answer  the  question, 
but  we  may  probably  infer  that  in  most  of  the  forty  cases, 
not  much  inquiry  is  made  of  applicants,  and  that  few  are 
excluded.  The  thirty-six  institutions  which  answered  the 
inquiry  positively,  treated  approximately  520,000  out-pa- 
tients in  1912.  One  of  the  thirty-six  reported  that  it  ex- 
cluded twenty  per  cent  of  the  applicants,*  one  other  reported 

*"The  Superintendent  of  the  institution  which,  in  1913,  reported 
this  high  percentage,  writes,  a  year  later,  as  follows:  'The  high  per- 
centage of  cases  turned  away  (in  the  report  of  last  year)  was  due  to  the 
5 


56  DISPENSARIES 

twelve  per  cent,  excluded,  another  eight  per  cent.  Five  of 
the  thirty-six  institutions  reported  between  two  per  cent, 
and  five  per  cent  of  applicants  excluded;  eight  sent  away 
between  two  per  cent,  and  one-half  of  one  per  cent,  and 
twenty-one  excluded  less  than  one-half  of  one  per  cent. 
The  actual  practice  in  thus  rejecting  such  a  small  proportion 
of  cases  has  been  partly  due,  no  doubt,  to  lax  admitting 
systems.  But  there  is  close  similarity  in  percentages  be- 
tween the  Dispensaries  just  quoted  and  those  institutions 
previously  cited,  which  had  given  careful  attention  to  ad- 
missions. '' 

The  purpose  of  the  particular  Dispensary  must  also 
be  considered.  Dr.  Veeder,  in  the  article  already 
referred  to,  has  well  stated  the  position  of  the  teaching 
Dispensary : 

"The  necessity  of  material  for  the  instruction  of  medical 
students  is  so  obvious  that  there  can  be  no  question  as  to 

fact  that  the  Dispensary  was  reorganized  and  rebuilt,  and  attracted 
to  it  a  large  number  of  men  employed  in  automobile  works  and  their 
famihes.  Hence  the  twenty  per  cent  turned  away  during  the  period 
following  reorganization.  In  the  Annual  Report,  forwarded  to  you 
under  separate  cover,  you  will  note  that  the  social  worker  turned 
away  one  and  one-third  per  cent  of  the  cases.  This  simply  covers 
the  cases  referred  to  her  by  the  admitting  officer,  who  could  not 
decide  the  standing  of  these  cases  at  the  time  of  their  application. 
In  addition  to  this  number,  the  admitting  officer  referred  back  to 
private  physicians  two  per  cent  of  first  applicants.  This  Dispensary 
is  thus  now  rejecting  three  and  one-half  per  cent  of  the  applicants.' 

"The  reason  for  rejecting  patients  at  many  institutions  is  not,  by 
any  means,  only  because  they  are  believed  to  be  able  to  pay  physicians. 
At  least  half  of  the  cases  at  the  institution  reporting  eight  per  cent 
excluded  are  turned  away  because  they  are  at  the  time  of  their  ap- 
plication under  treatment  at  another  institution.  In  cities  with 
several  Dispensaries  this  factor  accounts  for  a  considerable  proportion 
of  the  number  who  are  reported  as  not  admitted. " 


DISPENSARY  PATIENTS  57 

the  right  or  propriety  of  any  legitimate  medical  school 
conducting  a  Dispensary,  provided  it  has  a  fixed  rule  that 
any  patient  refusing  to  act  as  material  for  purposes  of  in- 
struction is  refused  admission.  Should  a  teaching  clinic 
lack  material  for  purposes  of  instruction,  it  might  with 
propriety  lower  its  standards  of  admission,  as  it  is  not  a 
purely  philanthropic  institution  and  the  end  in  view  justifies 
the  purposes  for  which  it  is  done.*  It  is  hardly  consistent 
for  a  physician  who  has  enjoyed  the  benefits  of  a  thorough 
medical  education  (the  average  cost  of  instruction  for  the 
four  years  being  around  $3,000  and  the  tuition  charges  from 
$600  to  $800)  to  object  to  a  clinic  connected  with  a  medical 
school  on  the  ground  that  the  clinic  lessens  the  financial 
returns  from  private  practice." 

The  point  of  view  of  the  public  health  must,  how- 
ever, be  paramount  at  all  times  to  all  other  considera- 
tions. The  public  health  Dispensary,  as  for  example 
the  tuberculosis  clinic,  must  consider  first  of  all  medical 
need,  represented  by  the  actual  or  potential  cases  of 
tuberculosis.  For  the  protection  of  the  patient,  the 
family  and  the  community,  treatment  must  be  pro- 
vided. The  relation  of  this  treatment  to  the  purposes 
of  medical  education,  or  to  private  medical  practice, 
must  be  secondary  considerations. 

The  answer  to  the  question  which  heads  this  chapter : 
'^Who  are  Dispensary  Patients?"  may  now  be  sum- 
marized. 

Dispensary  patients  include  many  persons  who  are 
below  the  poverty  line,  but,  in  much  larger  proportion, 

*  The  New  York  State  Board  of  Charities,  in  its  regulations  govern- 
ing the  Dispensaries  under  its  control  (see  page  45),  recognizes  this 
principle  with  respect  to  admission  of  patients  to  teaching  clinics. 


58  DISPENSARIES 

are  members  of  families  earning  the  incomes  most 
frequent  in  American  communities.  These  families 
are  not  dependent,  and  meet  their  ordinary  expenses, 
but  cannot  provide  margin  to  cover  the  expenses  of 
illness  or  the  cost  of  medical  care.  Many  of  these 
persons  do  not  secure  from  Dispensaries  all  of  their 
medical  service,  but  employ  physicians  from  time  to 
time.  They  usually  find  it  impossible,  however,  to 
pay  enough  to  secure  complete  service  and  are  wholly 
unable,  in  most  cases,  to  pay  for  consultation  or  for 
treatment  by  specialists.  The  experience  of  the  best 
administered  Dispensaries  in  the  United  States  shows 
that  only  a  minute  fraction  of  the  applicants  at  Dis- 
pensaries comes  with  the  intention  to  abuse  the  privi- 
leges of  the  institution.  The  great  majority  come  in 
good  faith,  seeking  what  they  believe  they  need  and 
cannot  otherwise  secure.  The  facts  indicate  that 
their  request  for  treatment  is  generally  justified  and 
also  raise  the  question  whether  thousands  of  persons 
who  are  in  the  same  circumstances,  but  to  whom 
Dispensaries  are  not  at  present  accessible,  have  not 
equal  need  of  their  services. 


DISPENSARY  PATIENTS  69 


CHAPTER  V 
WHO   SHOULD  BE  DISPENSARY  PATIENTS? 

Is  a  Dispensary  for  sick  people;  or  is  it  only  for 
sick  poor?     Who  are  ^'the  poor'7 

This  is  a  short  question  needing  a  long  answer. 
To  make  a  satisfactory  response,  we  must  give  careful 
consideration  to  the  fundamental  need  for  medical 
institutions  of  the  various  types.  The  response  to  the 
inquiry  which  heads  this  chapter  really  hinges  upon 
our  conception  of  the  Dispensary  itself.  In  earlier 
chapters  we  saw  that,  historically  and  practically, 
four  different  aims  can  be  traced  in  Dispensaries: — 

(a)  The  original  Dispensaries  were  founded  because  of  a 
charitable  desire  to  help  the  sick  poor  by  medicines  and 
medical  advice. 

(b)  The  rise  of  organized  clinical  teaching  as  a  part  of 
medical  education  has  caused  Dispensaries  to  be  developed 
as  parts  of  medical  schools  or  under  their  control. 

(c)  The  public  health  movement  has  in  recent  years 
resulted  in  the  estabhshment  of  hundreds  of  Dispensaries 
for  the  treatment  and  especially  the  prevention  of  certain 
diseases. 

(d)  Finally,  we  have  the  Dispensaries  organized  for 
the  co-operative  practice  of  medicine  on  a  scientific  but 
business  basis — of  which  the  Mayo  Clinic  is  a  type. 

Each  of  these  aims  dominating  a  Dispensary  in- 


60  DISPENSARIES 

volves  a  somewhat  different  relationship  between  it 
and  the  medical  profession. 

(1)  The  typical  Dispensary  maintained  as  a  charity  has 
depended  upon  volunteer  medical  service,  although  the 
payment  of  small  salaries  has  become  not  uncommon  in 
New  York  City,  and  in  a  few  cases  elsewhere. 

(2)  The  Dispensary  attached  to  a  medical  school  has 
also  been  accustomed  to  secure  medical  service  free,  al- 
though in  an  increasing  proportion  of  cases,  medical  schools 
of  standing  pay  salaries — in  some  instances,  full-time  sal- 
aries— to  the  clinical  as  well  as  the  research  and  the  labora- 
tory staffs;  and  the  men  receiving  these  salaries  give,  in 
many  instances,  a  portion  of  their  time  to  the  Dispen- 
sary. Whether  substantial  salaries  are  paid  or  not  to  the 
staff  of  a  Dispensary  in  a  medical  school  of  high  standing, 
it  is  safe  to  say  that  these  physicians  receive  directly  or 
indirectly  a  financial  compensation  for  their  dispensary 
service. 

(3)  In  the  Public  Health  Dispensaries,  the  medical  staff 
has  sometimes  been  volunteer,  but  often  salaried. 

(4)  In  the  Mayo  Clinic,  the  type  of  a  Dispensary  estab- 
lished to  provide  efficient,  organized,  medical  service  on  a 
business  basis,  the  physicians  receive  compensation  which 
must  be  sufficient  to  attract  and  to  hold  them,  in  compe- 
tition with  that  which  they  could  earn  in  private  practice. 

Because  of  the  somewhat  different  aims  of  these 
four  types  of  Dispensaries  and  their  different  relation- 
ship to  the  medical  profession,  each  type  may  properly 
maintain  a  different  policy  in  the  reception  of  patients. 

(a)  The  Dispensary  carried  on  as  a  charity  must  in 
general  play  fair  with  the  community  and  with  the  medical 


DISPENSARY  PATIENTS  61 

profession.  It  should  treat  only  those  who  are  unable  to 
pay  the  cost  of  the  medical  service  which  they  need,  at  the 
private  rates  usually  charged.  This  principle  was  com- 
paratively simple  in  apphcation  in  times  when  medical 
practice  itself  was  simple.  Medical  practice  now  involves 
many  varied  specialties,  and  increasingly  expensive  appara- 
tus and  methods  of  diagnosis  and  treatment.  Hence  it 
becomes  more  and  more  difficult  to  apply  this  principle 
accurately.  The  next  pages  will  be  chiefly  devoted  to  this 
practical  problem. 

(b)  The  Dispensary  which  is  primarily  a  teaching  institu- 
tion ordinarily  confines  its  clientele  to  the  same  type  of 
patient  as  the  charitable  Dispensary.  But  for  the  sake  of 
the  medical  education  for  which  it  is  maintained,  a  teaching 
Dispensary  may  properly  accept  any  patient  whose  disease 
would  render  him  of  especial  service  in  teaching  students, 
or  in  advancing  medical  knowledge. 

(c)  Dispensaries  established  for  public  health  purposes, 
as  to  combat  tuberculosis,  must  be  governed  primarily  by 
considerations  of  public  health,  which  often  have  nothing 
to  do  with  the  finances  of  the  patients,  or  of  the  medical 
profession  either.  Where  the  immediate  protection  of  the 
community  against  contagious  disease  is  involved,  the 
patient  must  be  accepted  and  placed  immediately  under 
care,  and  unless  there  is  complete  assurance  that  this  can 
be  done  through  some  other  means,  as  through  a  private 
physician,  the  public  health  Dispensary  must  not  refuse  the 
case.  The  same  consideration  operates  in  the  charitable 
dispensary,  e.g.,  a  man  with  syphilis  in  a  highly  infectious 
stage,  presents  himself  at  the  admission  desk.  He  is 
unmarried, — he  earns  $25  a  week, — he  has  savings, — he 
could  pay  for  some  treatment  in  a  doctor's  private  office; 
but  if  he  is  sent  away  with  a  reference  to  one  or  more  skilled 


62  DISPENSARIES 

\  physicians,  will  he  go?  He  may,  but  we  cannot  be  sure, 
and  dare  the  Dispensary  send  him  off  without  first  starting 
his  treatment  with  a  dose  of  salvarsan,  which  may  largely 
prevent  him  from  disseminating  further  infection? 

(d)  A  Dispensary,  which,  like  the  Mayo  Clinic,  represents 
the  organized,  co-operative  effort  of  a  group  of  physicians, 
on  a  business  basis,  is  merely  subject  to  the  same  conditions 
as  affect  physicians  in  private.  The  ethics  of  their  institu- 
tion are  the  ethics  of  their  profession.  If  they  accept  the 
rich,  they  may  charge  what  are  considered  fair  professional 
fees;  if  they  accept  the  poor,  they  may  do  as  a  private 
physician  in  his  private  office,  and  take  the  patient  for 
whatever  the  patient  can  pay. 

There  is  a  hoary  misconception  concerning  the 
meaning  of  ''charity."  Formerly  it  was  generally 
conceived  as  a  dole  to  the  destitute.  Unless  the 
recipients  were  unable  to  make  any  return  except  in 
gratitude,  the  gift  was  hardly  charity  at  all.  But  the 
modern  conception  of  charity  is  not  a  dole,  but  a 
service; — a  service  rendered  by  an  individual,  an 
organization  or  a  community,  to  persons  or  groups 
who  could  not  otherwise  obtain  the  benefit  provided. 

Ability  to  obtain  a  benefit  depends  partly  on  the 
income  or  opportunities  of  the  recipient  and  partly 
on  the  cost  of  the  thing  to  be  obtained.  Now  the 
cost  of  medical  service  supplied  by  Dispensaries  has 
changed  greatly  since  the  early  Dispensaries  began 
their  work,  and  especially  during  the  last  fifteen  years. 

The  old  Dispensaries  provided  merely  the  advice 
of  a  single  physician  and  medicine.  They  corre- 
sponded to  the  general  practitioner  before  the  days 


DISPENSARY  PATIENTS  63 

of  modern  scientific  methods  of  diagnosis.  The 
modern  Dispensary  provides  varied  and  expensive 
services  and  what  it  offers  its  patients  is  to  be  com- 
pared not  only  with  the  service  of  the  general  practi- 
tioner, but  with  that  of  the  specialist,  the  laboratory, 
or  the  X-ray  man. 

A  very  little  consideration  of  the  cost  of  treatment 
of  different  diseases  shows  within  what  wide  limits 
this  ranges.  A  minor  illness  might  require  a  couple 
of  office  visits  to  a  general  practitioner  and  a  little 
medicine.  All  this  might  cost  a  patient  S2.50  or 
$3.50.*  A  case  of  ^indigestion"  requiring  several 
examinations,  X-ray  and  care  for  a  considerable 
period  might  cost,  at  a  low  estimate,  $75  for  the  first 
six  months.  A  case  of  syphilis  requiring  salvarsani 
injections  would  cost  over  $100  for  the  same  period. 
Examinations  of  the  nose  and  throat  by  a  specialist 
and  operation  for  a  deviated  septum  with  the  neces- 
sary after-care,  would  cost  $50,  or  over.  Examination 
of  the  eyes  by  an  oculist,  with  provision  of  glasses 
not  unusually  expensive,  would  cost  $10.  The  super- 
vision of  a  little  baby  subject  to  digestive  upsets  might 
cost  $40  to  $60  within  six  months.  The  diagnosis 
and  supervision  of  a  case  of  adult  tuberculosis  at 
home  would  cost  $25  to  $30  during  the  same  period, 
not  including  the  expense  of  special  food.  Complex 
conditions  requiring  examinations  by  a  number  of 
different  specialists,  X-rays  and  various  laboratory 

*  It  will  be  obvious  that  these  statements  of  medical  cost  are  merely 
illustrative.  They  are  based  on  what  physicians  or  specialists  would 
probably  charge  patients  known  to  be  of  very  moderate  means. 


64  DISPENSARIES 

tests  might  cost  $100  or  $200  before  the  diagnosis  was 
reached. 

Thus  the  test  for  the  charitable  dispensary  is  not 
the  ability  of  the  patient  to  pay  "a  medical  fee,"  but 
to  pay  the  medical  fee  required  for  his  particular  case 
at  the  usual  rate  charged  by  competent  doctors  in 
his  community.  In  other  words,  cost  of  service 
needed,  in  relation  to  the  financial  ability  of  the 
patient,  is  the  real  test. 

The  broadening  of  the  range  of  dispensary  service 
medically  has  thus  greatly  broadened  its  scope  with 
respect  to  the  economic  classes  in  the  community. 
The  widely  varying  kinds  of  medical  and  surgical 
work  which  now  can  and  should  be  done,  and  their 
widely  varying  cost,  explain  why  even  the  charitable 
Dispensary  cannot  confine  its  work  to  any  particular 
economic  and  social  group  at  the  lower  level  of  the 
community.  The  higher  paid  wage-earners  and  the 
small-salaried  groups  need  its  services,  particularly 
in  the  specialties  and  in  difficult  cases  requiring  elab- 
orate consultation  and  special  tests. 

The  more  developed  the  medical  organization  of  a 
Dispensary  is,  and  the  higher  the  reputation  of  its 
Medical  Staff  along  their  various  lines,  the  more  surely 
and  the  more  justly  will  this  institution  draw  patients 
from  varied  classes  in  the  community.  Many  of 
the  patients  may  be  able  to  afford  ordinary  medical 
fees  but  need,  and  feel  they  ought  to  have,  special 
service  which  they  could  in  no  way  afford  to  pay  for 
at  private  rates.  This  consideration  applies  par- 
ticularly to  the  teaching  dispensary  attached  to  a 


DISPENSARY  PATIENTS  65 

medical  school  of  high  standing.  Such  a  dispensary 
may  well  fill  more  than  a  local  position  as  a  center  for 
diagnosis  and  consultation  as  well  as  for  treatment. 

Fees  from  Dispensary  Patients? 

The  antiquated  notion  of  charity  to  which  we  have 
often  referred  is  responsible  for  another  misconception, 
namely,  that  the  services  of  an  institution  like  the 
Dispensary  must  be  rendered  without  price.  There 
still  exist  those  who  wish  to  give  their  charity  straight; 
those  who  see  no  distinction  between  the  medical 
service  provided  by  a  hospital  or  dispensary  and  the 
pair  of  shoes  or  ^^ grocery  order"  furnished  by  a  relief 
society.  The  gradual  passing  of  this  point  of  view 
is  evidenced  by  the  fact  that  a  majority  even  of  the 
charitable  Dispensaries  of  this  country  now  charge 
small  fees  for  admission,  treatment  or  medicine,  or 
for  one  or  all  of  these.  There  has  been,  however, 
little  discussion  of  the  economic  and  moral  founda- 
tions of  the  fee  system  in  Dispensaries. 

It  is  obvious  that  whether  a  Dispensary  is  founded 
as  a  charity,  for  teaching,  or  for  public  health  service, 
it  must  not  charge  a  fee  based  merely  upon  the  cost 
of  the  service  rendered;  for  in  many  instances  this 
fee  would  be  too  high  to  help  many  of  those  who  need 
it,  and  the  institution  would  thus  defeat  its  purpose  of 
service.  On  the  other  hand,  practical  experience  of 
Dispensaries,  as  well  as  an  unprejudiced  considera- 
tion of  human  nature,  bears  out  the  belief  that  those  j 
who  pay  something,  even  ten  cents,  for  what  they; 
receive,  take  advice  or  treatment  more  seriously  and  \ 


66  DISPENSARIES 

I  feel  rather  better  about  accepting  the  service  than  if 

^  they  paid  nothing.  Most  people  are  built  this  way. 
Some  are  different.     The  dispensary  fee  system,  how- 

1  ever,  is  justly  based  upon  the  psychology  of  the 
majority. 

I  There  is  another  point  of  view,  namely;  that  serv- 
ices like  the  Dispensary,  providing  health  for  the 
=/  people,  ought  to  be  supported  by  general  taxation  and 
be  free  for  all  citizens.  Whether  or  not  this  point  of 
view  is  sound,  most  will  agree  that  until  medical 
service  is  a  state  function  (if  that  day  comes),  a  Dis- 
pensary, as  a  form  of  medical  service,  ought  to  con- 
form in  the  general  principles  of  its  operation,  with 
the  general  system  for  providing  medical  service  in 
the  community.  From  this  standpoint  there  is  no 
reason  why  Dispensaries  may  not  on  the  one  hand  be 
private  enterprises  like  the  Mayo  Clinic;  or,  on  the 
other  hand,  be  charitable  institutions.  They  cor- 
respond in  the  one  case  to  a  private  school,  in  the 
other  case  to  an  endowed  college.  In  either  instance 
there  is  no  reason  why  they  may  not  charge  fees. 

'  What  shall  be  the  relation  between  the  patients  of  a 
physician  in  a  Dispensary  and  in  private  practice? 
Should  patients  who  can  pay  the  usual  private  fees 
for  the  needed  medical  service  be  treated  in  a  Dis- 
pensary free,  or  for  nominal  fees?  If  such  persons 
apply  at  a  Dispensary  for  treatment,  shall  they  be 
referred  to  private  physicians,  and  in  particular  to 
the  Staff  of  the  Dispensary  itself?  What  shall  a 
physician  do  when  a  patient  in  the  clinic  seems  to  be 
in   sufficiently   good   circumstances   to   pay   private 


DISPENSARY  PATIENTS  67 

office  rates?  For  the  protection  alike  of  patient, 
physician  and  Dispensary,  it  is  necessary  to  establish 
a  policy  and  devise  a  procedure  by  which  the  selection 
of  patients  able  to  pay  private  fees  shall  be  made  by 
the  Dispensary,  and  the  patients  themselves  be 
referred  in  a  manner  which  will  be  likely  to  insure 
them  good  medical  treatment,  be  just  to  the  medical 
profession  and  beneficial  to  the  community. 

The  policy  which  should  govern  the  situation  may 
be  set  forth  in  a  few  simple  rules : — 

1.  A  charitable  Dispensary  aims  to  provide  the  best 
medical  treatment  for  those  who  cannot  otherwise  secure 
it.  It  aims  not  to  accept  patients  who  can  afford  to  pay 
the  usual  private  rates  for  the  medical  care  which  they 
require. 

2.  The  admitting  officer  of  the  Dispensary,  under  its 
Superintendent  and  Trustees,  should  be  responsible  for 
determining  the  circumstances  of  the  patient  and,  after 
consideration  of  the  patient's  income,  family  responsibilities, 
and  the  probable  cost  of  the  medical  treatment  required, 
for  deciding  whether  the  patient  should  be  treated  in  a  free 
clinic,  a  pay  clinic,  or  in  the  private  office  of  a  physician. 

3.  The  reference  of  the  patient  to  the  proper  agent  for 
treatment  should  be  made  by  the  admitting  officer,  or  other 
administrative  official  of  the  Dispensary,  not  by  a  member 
of  the  Medical  Staff. 

4.  Due  records  should  be  made  of  each  case  thus  referred 
for  treatment  outside  of  the  Dispensary. 

5.  No  physician  should  solicit  private  practice  from 
patients.* 

In  carrying  out  such  a  policy  effectively,  the  chief 
requisite  is  a  well-organized  admission  system,  under 

♦Compare  By-laws,  pages  415-426. 


68  DISPENSARIES 

a  competent  head.  Most  of  the  difficulties  which 
arise  are  due  to  a  lack  of  this.  The  medical  staff  must 
be  fully  informed  of  the  policy.  They  should  under- 
stand that,  should  a  patient  appear  in  a  clinic  whom  a 
physician  thinks  has  not  been  properly  judged  by  the 
admission  desk,  the  patient  is  to  be  sent  back  to  the 
admission  desk  for  reconsideration  and  further  refer- 
ence. The  question  then  arises,  to  whom  shall  the 
admission  desk  refer  a  case  needing  private  treat- 
ment? In  general  it  seems  just  that  such  a  patient 
be  given  the  names  of  one  or  more  members  of  the 
staff  of  the  clinic  to  which  his  disease  would  naturally 
assign  him.  Cases  also  arise  in  which  the  patient  asks 
at  the  admission  desk  for  the  name  of  a  competent 
doctor,  or  himself  solicits  a  physician,  in  the  clinic, 
for  private  treatment.  When  a  patient  does  this  the 
physician  should  report  the  fact  to  the  admission  desk, 
or  to  the  representative  of  the  admitting  officer  in 
the  clinic  (the  social  worker,  nurse,  or  clerk).  The 
admitting  office  or  its  representative  will  then  refer 
the  patient  to  the  physician,  but  due  record  will  be 
made  of  the  fact  upon  the  patient's  record  card  and 
elsewhere.  Solicitation  of  private  practice  by  physi- 
cians in  clinics  should  be  regarded  by  the  adminis- 
trative authorities  of  the  Dispensary  and  by  its  Med- 
ical Staff,  as  unprofessional  conduct. 

What  shall  dispensary  fees  be,  how  much  and 
how  determined?  They  should  clearly  follow  the 
traditional  ethical  rules  of  the  medical  profession,  ''not 
refusing  service  to  anyone  really  needing  it,  whether 
the  fee  levied  can  be  paid  or  not."     But  how  shall 


DISPENSARY  PATIENTS  69 

the  general  level  of  the  fees  be  determined,  understand- 
ing that  partial  or  complete  remission  of  fee  will 
always  be  made  in  suitable  cases? 

In  private  medical  practice  the  fee  received  by  the 
physician  is  partly  a  compensation  for  his  medical 
service  and  partly  payment  for  the  expenses  he  must 
meet  in  maintaining  his  office,  his  assistants,  his 
equipment,  automobile,  etc.  In  the  medical  institu- 
tions the  appliances,  instruments,  laboratory,  nursing, 
etc.,  are  provided  for  the  doctor.  When  a  Dispen- 
sary not  organized  for  profit  does  not  pay  its  physi- 
cians, it  may  charge  fees  not  averaging  more  than  the 
cost  of  the  services  rendered,  excluding  any  charge 
for  the  medical  service  as  such.  Were  this  principle 
strictly  carried  out,  the  physician  giving  his  time  in 
the  Dispensary  would  receive  no  money,  and  the  fee 
paid  by  the  patient  would  no  more  than  meet  the 
strictly  administrative  expenses.  These,  on  the  aver- 
age, would  be  less  than  those  required  to  maintain  an 
equivalent  medical  service  in  a  single  private  ofiice. 

If  fees  at  a  Dispensary  are  on  the  average  higher 
than  the  administrative  costs,  then  the  clinic  becomes 
a  pay  clinic  and  the  amount  of  the  fees  received  above 
the  administrative  costs  should  go  to  the  medical 
profession,  either  directly  in  salaries  to  the  Staff,  or 
in  some  fashion  approved  by  them,  for  the  advance- 
ment of  medical  science  or  medical  education.  In 
practice  the  usual  rates  of  fees  in  the  charitable  Dis- 
pensaries of  this  country  at  the  present  time  cover 
from  one-fifth  to  one-half  the  administrative  cost.* 

*  Fee  schedules  for  practical  use  in  Dispensaries  are  on  pages  275  et  seq. 


70  DISPENSARIES 

Summary 

The  principles  outlined  in  this  chapter  may  be 
summarized  as  follows: 

1.  With  the  widely  varying  cost  of  different  medical 
services  at  the  present  time,  and  the  complex  char- 
acter of  our  population  and  its  needs,  the  clientele  of 
the  Dispensary  should  not  be  confined  to  the  '^poor/' 
or  to  any  single  social  group. 

2.  Who  then  should  be  dispensary  patients?  Those 
who  need  dispensary  service  and  cannot  secure  equiva- 
lent medical  service  otherwise. 

3.  Remuneration  of  dispensary  staffs  must  accom- 
pany extension  of  dispensary  service  above  the  low 
income  levels  of  the  population. 

4.  The  regulations  for  admitting  patients,  the  fees 
for  treatment  and  the  compensation  for  those  who 
do  the  work,  must  be  thoughtfully  adapted  to  each 
of  the  particular  groups  in  the  community  who  need 
what  the  Dispensary  has  to  offer.  An  efficient  ad- 
ministration of  the  Dispensary  according  to  these 
policies  will  confer  benefit  upon  both  the  public  and 
the  medical  profession. 


ESSENTIALS   OF  A  CLINIC  71 


CHAPTER   VI 
THE  TEN   ESSENTIALS   OF  A   CLINIC 

The  purpose  of  an  institution  is  the  determining 
fact  over  its  organization.  After  all,  organization  is 
only  a  means  to  an  end.  To  organize,  means  merely 
to  arrange  certain  elements  in  such  ways  and  in  such 
relation,  that  they  shall  operate  together  efficiently 
to  accomplish  certain  results.  If  we  see  very  clearly 
the  ultimate  purpose,  good  organization  is  likely  to 
follow. 

The  purpose  of  a  Dispensary  may  be  defined  as: 
Service  to  the  community  through  service  to  sick  people. 
We  must  not  be  content  to  define  this  purpose  as 
simply  the  medical  care  of  patients.  That  is  too 
narrow  a  definition,  for  very  often  the  illness  of  the 
man,  woman  or  child  who  comes  to  the  dispensary 
door,  cannot  be  dealt  with  merely  as  a  disease  of  an 
individual  body.  The  words  that  Virchow  inscribed 
over  the  portal  of  his  great  hospital  deserve  to  be 
placed  over  the  door  of  every  Dispensary,  for  they 
describe  accurately  the  thought  which  this  definition 
aims  to  convey: 

'^ Treat  Not  Only  the  Disease;  Treat  Also  the 

Man.'' 
The  man  is  a  citizen  as  well  as  a  patient.     The 
Dispensary  must  consider  its  obligations  to  the  com- 


72  DISPENSARIES 

munity  as  well  as  to  the  individual;  and  it  must  labor 
for  prevention  as  well  as  for  cure  of  disease.  As  the 
clinical  symptoms  indicate  the  disease,  so  the  disease 
may  indicate  the  man — his  habits,  his  living,  his 
work;  in  cases  of  contagion  his  associates  or  in  heredi- 
tary conditions  his  antecedents;  these  in  turn  may 
indicate  unnecessary  faults  in  industrial  or  living 
conditions;  they  may  call  for  community  action,  as 
upon  water  or  milk  supply;  they  may  require  public 
regulation  of  conditions  in  factories  or  in  tenement- 
houses.  We  need  consideration  of  the  man  as  well 
as  of  the  disease,  because  only  through  knowledge  of 
the  larger  problem  can  come  adequate  treatment  and 
permanent  results.  We  plead  also  for  such  a  con- 
sideration of  the  individual  patients  that  we  may  learn, 
from  them,  the  symptoms  of  the  diseases  of  society. 
It  is  just  as  important  that  a  correct  diagnosis  be  made 
of  sociological  defect  among  the  unfortunates  com- 
pelled to  suffer  because  of  this  defect,  as  it  is  that  a 
correct  diagnosis  of  the  individual  patient's  disease 
be  made  from  the  medical  symptoms  presented. 
There  is  every  reason  then  to  encourage  the  most 
thoughtful  consideration  of  the  whole  problem  pre- 
sented by  the  patient,  in  its  medical,  public-health 
and  sociological  aspects. 

If  we  conceive  the  patient  in  this  broad  way,  we 
may  rightly  say  that  he  is  the  central  feature  on 
which  all  dispensary  organization  hinges. 

''About  matters  of  organization,"  said  Mr.  Robert 
G.  Valentine  in  a  notable  article,"  ''we  still  have  much 
to  learn.     The  truly  wise  among  us  are  not  dogmatic, 


ESSENTIALS  OF  A  CLINIC  73 

but  questioners  on  a  pioneer  journey.  But  it  seems 
to  be  a  fairly  sound  hypothesis  that  in  building  up 
an  organization  we  should  build  from  the  bottom  up, 
or  to  take  a  military  simile,  from  the  firing  line  back, 
or  to  take  a  factory  simile,  from  the  workers  back. 
Take  for  example  the  soldier  in  the  trench.  The 
whole  military  organization  of  that  soldier's  country, 
including  its  industrial  and  social  aspects,  can  be 
tested  out  by  asking,  both  in  the  field  and  at  home, 
whether  eveything  that  is  planned  and  done  helps 
the  man  in  that  trench.  Everything  that  does  not 
help  him  or  that  hinders  him,  is  worse  than  unneces- 
sary." 

The  primary  factors  in  a  Dispensary  are,  therefore, 
the  patient  and  the  doctor,  and  the  final  purpose  of 
the  whole  organization  is  to  render  the  service  of  the 
doctor  to  the  patient  most  effective,  when  these  two 
are  face  to  face. 

If  Virchow's  broad  conception  of  the  patient  as  a 
man  and  a  citizen  is  to  be  followed  as  it  should  be, 
then,  within  each  clinic,  as  within  the  Dispensary  as  a 
whole,  the  elements  to  be  dealt  with  are  not  wholly 
medical,  but  are  also  social  and  administrative.  The 
agents  who  carry  on  the  actual  work  are  Hkewise  not 
only  physicians  and  nurses,  but  also  social  workers, 
engineers,  clerks,  cleaners,  executives  and  advisors. 
This  is  graphically  illustrated  in  the  accompanying 
diagram. 


74 


DISPENSARIES 


DISPENSARY  ORGANIZATION 


Units  of  Organization, 
present  in  every  Dis- 
pensary (depending 
on    the     specialties 
included) 


Clinics 


Elements  of  Organiza- 
tion, present  in  each 
unit 


Agents  of 
Hon,  in 
ment 


Organiza- 
each   ele- 


Medical 


Doctor 


Surgical 


Pediatrics 

and 

a  dozen  or  so  other 

Specialties 


1.  Medical — doing  the 
essential  professional 
work 


2.  Social — hitching 
this   work   up   with 
community  forces 


3.  Administrative — 
making  favorable 
conditions    for    the 
performance   of   the 
work 

f  maintaining   plant 
•  \  and  equipment  and 

'  correlating  the 
various  units,  ele- 
V      ments  and  agents 
)  into    an    eflicient, 
harmonious  organ- 
ization 


In  this  chapter  is  outUned  the  proper  internal  con- 
stitution, so  to  speak,  of  the  unit  of  dispensary  organ- 
ization, the  Clinic.  The  details  of  certain  of  the 
essential  factors  are  presented  later  in  separate  chap- 
ters. In  the  succeeding  chapter  there  naturally 
follows  an  account  of  the  general  organization  which 
should  co-ordinate  all  the  clinical  units  into  a  working 
whole. 


Clinical 
Laboratory 

Nurse 

Attendant 

Pharmacist 

X-ray  Technician 
,  Masseur,  etc. 

'  Social  Workers  of  the 
Social  Service  De- 
partment 
Correlated  Social 
Welfare  Agencies  of 
the  Community 


'  Board    of    Trustees, 
Executive  and  Med- 
ical Committees, 
Executive  OflBcer, 
Assistant  Executives, 
Engineers,   Janitors, 
Cleaners,  Clerks, 

,  Orderlies,  etc. 


ESSENTIALS   OF  A  CLINIC  75 

The  essential  requirements  of  an  efficient  out- 
patient clinic  are  ten: — 

(1)  Medical  Staff:  Adequate  in  number  for  each 
clinic  and  effective  as  to  internal  organization. 

(2)  Co-operative  Organization:  A  general  system  of 
organization  for  the  Dispensary  as  a  whole,  which 
relates  the  different  clinics  so  as  to  promote  good 
co-operative  work. 

These  two  requirements  are  treated  in  more  detail  in 
Chapter  VII.  Since  the  different  specialties  vary  in  some 
degree  in  what  they  require  of  their  Staff,  as  for  example,  in 
the  number  of  physicians  needed  to  care  properly  for  a  given 
number  of  patients,  certain  details  are  left  to  the  sections 
in  Chapter  X,  devoted  to  each  special  clinical  department. 
Chapter  XII  deals  with  the  admission  system,  a  very 
important  element  in  an  efficient  co-operative  organization. 

(3)  Space  and  Equipment:  Proper  space  and  arrange- 
ment of  the  rooms  of  the  clinics,  and  adequate  tech- 
nical equipment  for  diagnosis  and  treatment. 

Chapter  IX  treats  of  the  construction  and  arrangement 
of  dispensary  buildings  in  general;  equipment  is  treated  in 
Chapters  X  and  XL 

(4)  Records:  Adequate  written  records  of  work  done 
in  the  clinics. 

Record  forms  and  methods  of  filing  and  utilization  are 
treated  in  Chapter  XIII. 

(5)  A  Follow-Up  System:  A  system  for  the  super- 
vision of  the  attendance  of  patients. 

Without  a  system  of  supervising  and  controlling  the 
attendance  of  patients,  the  physicians  of  a  clinic  work  in  the 


76  DISPENSARIES 

\  dark.  With  it,  treatment  of  patients  in  a  clinic  affords 
opportunities  which  equal  or  surpass  those  in  private  prac- 
tice for  continuous  and  effective  supervision  of  cases.  This 
will  be  dealt  with  in  Chapter  XIV. 

(6)  Nursing:  Assistance  to  the  physicians  in  the 
personal  care  of  patients  in  the  clinics. 

The  general  organization  of  the  nursing  service  will  be 
referred  to  in  Chapter  VII.  Since  the  exact  requirements 
for  nursing  vary  widely  in  different  clinics,  these  will  be 
touched  upon  in  Chapters  X  and  XI  under  the  heading  of 
each  department. 

(7)  Social  Service:  Assistance  to  the  physicians  in 
the  education  of  the  patient,  and  in  the  control  of  his 
environment. 

To  this  Chapter  VIII  is  devoted.  Some  reference  is  also 
made  to  the  general  organization  of  Social  Service  in  Chap- 
ter VII. 

(8)  Executive  Assistance:  Assistance  to  the  physi- 
cians in  the  prompt,  orderly  and  kindly  management 
of  the  clinics. 

How  this  may  be  provided  is  discussed  in  the  next  Chap- 
ter and  in  Chapters  X  and  XI. 

(9)  Clerical  Aid:  Assistance  to  the  Physicians, 
Social  Workers  and  Executive  Officers  with  records 
and  other  clerical  work. 

(10)  Efficiency  Tests:  Periodical,  critical  examina- 
tion of  records;  estimation  and  tabulation  of  medical 
and  social  results. 


ESSENTIALS  OF  A  CLINIC  77 

Examples  of  efficiency  tests  and  methods  of  pursuing 
them  in  chnics  are  described  in  Chapter  XV. 

Consider  a  small  medical  clinic  receiving  ten  or 
twelve  patients  a  day.  A  single  physician  with  one 
woman  assistant,  whom  we  will  assume  to  be  a  nurse 
with  training  in  social  service,  might  perform  all  the 
work.  The  physician  would  spend  an  average  of 
twenty  minutes  with  each  new  patient,  and  five  to 
ten  minutes  with  each  old  patient,  and  the  clinic 
would  be  finished  in  two  hours.  The  physician  and 
his  aide  would  divide  between  them  all  of  the  different 
functions  indicated  in  the  above  list.  There  are 
five  of  these  functions  which  have  to  be  performed  by 
persons:  (1)  medical,  (2)  nursing,  (3)  social,  (4)  execu- 
tive, and  (5)  clerical.  In  this  little  clinic,  the  physi- 
cian would  perform  the  medical  functions  and  most 
of  the  executive  functions.  The  nurse,  however, 
would  interview  each  new  patient,  take  a  social  his- 
tory, record  temperature  and  weight,  and  prepare  the 
women  patients  for  examination.  The  doctor  would 
do  some  of  the  clerical  work.  His  aide  would  do  the 
nursing  and  the  social  work,  and  a  share  of  the  clerical 
tasks.  If  the  physician's  assistant  were  a  nurse  with- 
out social  training,  he  might  then  secure  his  social 
service  by  calling  in,  from  the  Social  Service  Depart- 
ment of  the  institution,  a  worker  to  see  patients 
whom  he  thought  presented  a  social  problem.  In 
this  case  the  physician  would  be  performing  one  of 
the  primary  parts  of  the  social  worker's  function, 
namely:  deciding  on  a  preliminary  social  diagnosis. 


78  DISPENSARIES 

Thus  the  five  functions  which  have  to  be  performed 
by  persons,  may  be  split  up  among  several  individuals 
or  united  in  a  few.  The  extent  to  which  specialization 
among  different  persons  is  carried  depends  on  the 
size  of  the  clinic,  and  the  extent  to  which  trained 
persons  are  available  to  perform  the  several  special- 
ized duties. 

This  may  be  seen  more  readily  by  contrast  between 
the  clinic  having  ten  or  twelve  patients  a  day,  as 
described  above,  and  a  large  medical  clinic  receiving, 
say  sixty  a  day.  Men  and  women  in  these  numbers 
will  have  to  be  separated  into  different  rooms,  whereas 
in  the  very  small  clinic  they  may  be  seen  successively, 
as  in  a  doctor's  private  office,  in  the  same  room.  We 
will  assume  that  the  medical  staff  of  this  large  clinic 
includes  seven  physicians;  one  chief,  who  is  in  general 
charge,  and  three  assistants  of  whom  half  work  with 
the  men  and  half  with  the  women  patients.  A  nurse, 
or  a  trained  attendant,  assists  with  the  women  pa- 
tients in  preparing  them  for  examination,  and  attend- 
ance during  examinations  when  necessary.  A  social 
worker  is  on  the  women's  side  and  another  on  the 
men's  side,  available  for  consultation  with  the  patient, 
and  with  patient  and  physician  as  required.  The 
executive  management  of  this  clinic,  with  so  many 
patients  and  doctors,  may  fall,  in  part,  to  the  chief 
of  the  department  and  certain  executive  duties  must 
fall  to  him,  since  they  involve  the  direction  of  the 
assistant  physicians.  The  management  of  the 
patients, — however,  seeing  that  they  come  promptly 
to  the  particular  physician  whom  they  are  to  see,  at 


ESSENTIALS   OF  A  CLINIC  79 

the  time  when  he  is  ready  to  see  them;  seeing  that 
their  records  are  ready  and  in  order,  and  all  the  other 
details, — should  properly  fall  to  a  clinic  secretary  or 
manager,  whose  duties  are  to  keep  the  machinery 
going  and  who  is  in  the  position  of  an  executive  assist- 
ant to  the  physician  in  charge. 

Such  a  clinic  would  be  in  session  from  two  to  three 
hours.  The  physician-in-chief  would  himself  see 
patients  upon  whom  his  assistants  may  desire  his 
opinion,  he  would  see  all  patients  referred  for  diag- 
nosis from  other  departments  of  the  Dispensary,  and 
would  in  addition,  settle  a  variety  of  medical  or 
administrative  questions  which  would  be  referred  to 
him  by  his  medical  or  lay  assistants.  The  clerical 
work  of  the  clinic  would  be  performed  by  a  clerk, 
attached  to  the  clinic,  who  might  spend  all  her  time 
therein.  Assistance  from  a  clerk  or  stenographer  in 
a  central  office  would  be  required  for  writing  special 
records,  etc.  If  the  clinic  is  a  teaching  clinic,  medical 
students  may,  in  so  far  as  they  write  down  the  patient's 
history  or  other  information  under  the  supervision 
of  their  instructor,  perform  a  part  of  the  clerical  tasks. 
Thus,  in  a  clinic  of  this  size  the  several  functions  will 
each  be  delegated  to  a  particular  person  or  persons. 

Until  recently,  out-patient  clinics  were  Hke  Topsy, 
they  ''just  growed.''  They  ran  themselves,  the 
doctor  thinking  particularly  about  the  ''interesting 
cases"  and  little  about  the  other  cases;  the  clinic 
being  '^run  off "  in  whatever  way  the  doctors,  without 
trained  help,  could  manage  to  "run''  it.  Now  the 
out-patient  clinic  is  conceived  as  a  place  wherein 


80  DISPENSARIES 

serious  and  efficient  medical  work  can  be  and  is  to  be 
done  for  everyone  admitted  to  it.  It  is,  therefore, 
essential  to  have  definite  organization,  and  thoughtful 
planning.  Every  one  of  the  five  functions,  medical, 
nursing,  social,  executive  and  clerical,  must  be  thought 
of  and  provided  for,  or  efficiency  cannot  be  attained. 
The  details  of  the  distribution  of  the  functions  will 
depend  on  the  size  of  the  clinic,  the  character  of  the 
medical,  surgical  or  special  work,  the  kind  of  trained 
persons  available  and  on  other  considerations.  These 
have  been  illustrated  by  describing  two  typical  clinics, 
widely  divergent  in  size. 

Equally  true  is  the  need  of  detailed  thoughtful 
consideration  of  the  five  other  conditions  of  efficiency: 
co-operative  organization,  space  and  equipment,  rec- 
ords, follow-up  system  and  efficiency  tests.  Careful 
analysis  of  what  each  clinic  of  a  given  institution 
needs,  in  each  of  these  respects,  is  the  responsibility 
not  only  of  its  medical  staff,  but  no  less  of  the  execu- 
tive officer  and  the  trustees  or  advisors  of  the  institu- 
tion. To  each  of  these  points  a  special  chapter  is 
devoted. 


ORGANIZATION  81 


CHAPTER  VII 

THE  MEDICAL  AND  ADMINISTRATIVE  ORGANIZA- 
TION  OF  A  DISPENSARY 

Whether  a  Dispensary  is  large  enough  to  include 
five  hundred  persons  on  its  medical,  social  and  admin- 
istrative staffs,  or  whether  its  personnel  consists  of  a 
doctor,  a  nurse  and  a  janitor,  the  elements  that  need 
to  be  organized  and  the  principles  of  that  organization 
are  the  same.  Of  course,  the  application  of  the  prin- 
ciples will  vary  in  the  extreme. 

I.  General  Principles 

The  ultimate  authority  in  the  institution  is  ordi- 
narily the  Board  of  Trustees.  The  superintendent  is 
the  Board's  representative.  Where  the  Dispensary 
is  unconnected  with  a  hospital,  the  one  primary  de- 
mand is  that  the  Board  of  Trustees  shall  be  interested 
and  the  superintendent  be  competent  and  be  given 
adequate  authority.  Where  the  Dispensary  is  the 
out-patient  department  of  a  hospital,  the  same  holds 
true,  but  the  superintendent  of  a  large  hospital  has 
not  much  time  to  give  personally  to  the  out-patient 
department,  and  it  is  then  essential  that  there  be  a 
responsible  paid  representative  in  the  out-patient 
department,  if  the  organization  is  to  be  well  worked 
out. 


82  DISPENSARIES 

But  going  farther  back,  the  effectiveness  of  the 
Dispensary  depends  not  merely  upon  the  medical 
men,  nor  upon  the  purely  executive  duties  of  the  super- 
intendent and  his  subordinates,  but  upon  the  way  the 
organization  is  planned  as  a  whole.  In  order  that 
the  work  of  a  Dispensary  be  efficient,  there  must  be  a 
competent  executive  head  who  has  authority.  In 
order  that  the  form  of  the  organization  and  its  policies 
be  well  thought  out,  there  must  be  a  policy-forming 
body  which  has  a  definite  interest  in  the  Dispensary 
or  the  out-patient  department.  This  policy-forming 
body  may  be  composed  of  the  Trustees  and  the  Super- 
intendent; or  the  Trustees,  the  Superintendent  and 
the  members  of  the  Medical  Staff;  or  it  may  be,  as  in 
some  institutions  it  is,  composed  of  a  Committee  of 
the  Medical  Staff  acting  with  the  Superintendent,  the 
reserve  powers  of  the  Trustees  being  rarely  exercised 
except  in  matters  of  major  importance,  or  except  on 
a  recommendation  from  the  active  committee.  Too 
often  out-patient  departments  of  hospitals  have  been 
run  second-hand,  or  at  long  range,  by  superintendents 
who  had  little  time  to  go  into  ''the  out-patient,"  or 
by  a  Committee  of  Trustees  or  medical  men,  whose 
interests  were  almost  exclusively  in  the  hospital 
wards.  The  two  essential  requirements  of  efficient 
management  of  either  an  out-patient  institution 
separate  from  a  hospital,  or  an  out-patient  depart- 
ment of  a  hospital,  are,  therefore: 

1.  The  shaping  of  the  Dispensary's  policy  by  an  official 
or  a  committee  who  are  held  responsible  for  the  Dispensary 
and  who  have  real  reason  to  be  interested  in  it. 


ORGANIZATION  83 

2.  The  execution  of  the  poHcy  and  of  the  details  of  the 
Dispensary's  work  l)y  a  responsible  head  with  adequate 
authority. 

How  these  principles  should  be  actually  worked 
out,  can  best  be  taken  up  after  some  preliminary 
details  of  dispensary  organization  have  been  con- 
sidered.* 

2.  Organization  of  the  Medical  Units 

A  clinical  department  has  two  aspects.  It  is  a 
medical  unit,  gathering  together  the  diseases  relating 
to  a  definite  specialty.  It  is  also  an  administrative 
unit,  and  from  this  standpoint  a  Dispensary  with  a 
given  number  of  patients  will  be  conducted  at  the 
maximum  of  administrative  efficiency  if  it  has  not 
more  than  a  certain  number  of  Departments.  Exam- 
ples could  be  cited  of  Dispensaries  receiving  an  aver- 
age of  only  fifty  patients  a  day,  which  have  as  many 
as  sixteen  different  clinical  departments,  of  which  as 
many  as  seven  to  ten  may  be  open  at  the  same  time. 
On  the  other  hand,  there  are  Dispensaries  of  ten 
times  the  size  that  have  not  more  than  nine  depart- 
ments. A  Dispensary  with  only  fifty  visits  a  day  is, 
from  the  administrative  standpoint,  running  its  work 
uneconomically,  if  it  has  sixteen  departments.  Each 
administrative  unit  complicates  the  distribution  of 
patients,  and  increases,  in  a  definite  degree,  the  labor 
and  expense  of  all  administration.     From  a  medical 

*In  the  Appendix  (pp.  415-26)  are  some  suggestions  for  the  By-laws 
of  a  Dispensary  and  of  an  out-patient  department,  incorporating  the 
principles  of  this  chapter. 


84  DISPENSARIES 

standpoint,  it  is  not  desirable  to  have  very  few  patients 
in  a  single  department.  The  reason  that  many  Dis- 
pensaries, receiving  from  forty  to  one  hundred  patients, 
have  an  unduly  large  number  of  departments,  is 
because  it  is  often  easier  to  secure  the  medical  serv- 
ice (this  being  volunteer)  when  the  title  of  Chief 
of  a  department  can  be  given,  than  if  the  same  man 
is  invited  to  come  into  a  larger  department  as  an 
assistant. 

The  general  considerations  which  should  determine 
the  number  of  different  departments  are,  first,  the 
number  of  specialties  which  are  actually  well  recog- 
nized in  the  medical  practice  of  the  community.  To 
be  ''well  recognized'^  in  a  community  means  that 
there  are  local  physicians  who  devote  all  or  almost  all 
of  their  time  to  the  pursuit  of  the  specialty.  Obvi- 
ously the  number  of  recognized  specialties  will  depend 
largely  on  the  size  of  the  community,  although  the 
existence  of  a  medical  school  and  of  a  teaching  hospital, 
with  a  more  or  less  salaried  staff,  may  cause  the  pres- 
ence of  specialists  who  would  not  be  supported  merely 
by  the  private  practice  of  the  town. 

In  any  Dispensary  aiming  to  deal  with  general 
diseases  the  following  three  departments  are  funda- 
mental : 

Medical 

Surgical 

Pediatric. 

In  some  small  communities,  there  may  be  no  physi- 
cians who  confine  their  private  practice  to  children, 


ORGANIZATION  85 

but  there  will  almost  always  be  some  who  give  special 
attention  to  them. 

The  following  three  should  come  next: 

Nose,  Throat  and  Ear 

Eye 

Dental. 

Even  in  communities  of  moderate  size,  these  will 
be  recognized  as  specialties,  diseases  of  the  eye  being 
not  infrequently  cared  for  by  the  same  men  who  treat 
nose,  throat  and  ear. 

A  Dispensary  not  connected  with  a  teaching  insti- 
stution  may  wisely  draw  the  line  at  this  point  unless 
there  can  be  found  in  its  community  men  who  are 
specializing  in,  and  are  recognized  as  competent  in, 
branches  such  as  the  following: 

Neurology 

Genito-Urinary 

Gynecology 

Orthopedics 

Dermatology 

Tuberculosis. 

The  alternative  to  creating  a  separate  department, 
in  many  instances,  is  the  assigning  of  a  physician  to  a 
special  Hne  of  work  within  a  general  department. 
Thus  a  man  particularly  interested  in  nerve  diseases 
may,  as  an  assistant  physician  in  the  general  medical 
department,  be  assigned  all  or  most  of  the  nerve 
cases.  On  the  surgical  side,  given  men  who  have  an 
inclination  toward  gynecology,  genito-urinary  or 
orthopedic  work,  similar  specialization  may  be  devel- 


86  DISPENSARIES 

oped.  In  this  way  men  may  be  trained  in  special 
lines  of  work  and  later,  if  desirable,  a  separate  de- 
partment can  be  created  for  them. 

The  Dispensary  of  small  size,  located  in  or  near  a 
large  city,  especially  should  bear  this  in  mind,  as  in 
such  institutions  the  pressure  is  greatest  to  swell  the 
number  of  departments  beyond  the  point  which  can 
be  efficiently  maintained  by  the  income  of  the  insti- 
tution. 

In  the  specialization  of  work  within  the  department 
there  are  further  possibilities.  In  this  way  it  is 
possible  for  thinking  and  ambitious  men,  although  in 
private  practice,  to  assemble  sufficient  material  for 
the  systematic  and  careful  observation  necessary  for 
advanced  study  and  research  work.  Such  oppor- 
tunities will  not  only  make  dispensary  positions 
eagerly  sought  by  the  highest  type  of  men,  but 
encourage,  in  fact  compel,  the  most  careful  considera- 
tion and  treatment  of  each  case,  thereby  increasing 
the  value  of  dispensary  work  to  the  patient  and  to  the 
community.  In  the  larger  Dispensaries  there  is  also 
the  possibility  that  if  this  specialization  be  developed 
and  through  it  active,  progressive  men  be  attracted 
to  the  staff  and  retained  a  long  time,  the  work  of 
these  men  will  prove  to  be  a  great  post-graduate,  as 
well  as  undergraduate  teaching  force  for  the  medical 
profession. 

A  conflict  arises  between  the  medical  and  adminis- 
trative interests  in  another  way,  namely  the  extent 
to  which  the  departments  shall  be  operated  simul- 
taneously.    For  the  purposes  of  co-operative  diag- 


ORGANIZATION  87 

nosis  and  treatment,  the  Dispensary  is  most  efficient 
when  all  departments  are  at  work  at  the  same  time, 
for  then  consultation  is  possible  by  word  of  mouth  as 
well  as  by  the  interchange  of  records.  But  this  makes 
demands  on  the  building,  and  faces  the  institution,  as 
a  rule,  with  the  apparent  uneconomy  of  having  a 
large  number  of  rooms,  all  used  from  two  to  four 
hours  daily  and  all  idle  the  other  four.  Some  institu- 
tions, like  the  Mt.  Sinai  Hospital  in  New  York,  run 
morning  and  afternoon  clinics,  each  a  complete  set, 
with  medical  staffs  largely  or  wholly  different;  but  in 
the  main,  so  long  as  Dispensaries  depend  on  medical 
staffs  whose  members  receive  little  or  no  salaries  for 
their  work,  the  clinics  will  be  limited  to  two  to  four 
hours  of  activity  a  day,  and  it  will  often  be  difficult  to 
secure  enough  space  for  their  simultaneous  operation. 
But  every  effort  should  be  made  to  do  so. 

The  list  of  departments  thus  far  considered  does  not 
include  those  which,  like  the  Laboratory  and  X-ray, 
are  secondary  to  clinics :  secondary  in  the  sense  that 
patients  are  not  sent  to  them  for  diagnosis  directly 
from  the  admission  desk.  These  departments  receive 
patients  (or  laboratory  specimens  taken  from  patients), 
when  sent  by  physicians  in  the  primary  departments. 
The  vital  diagnostic  importance  of  the  Laboratory 
and  the  X-ray  need  not  be  emphasized  here;  their 
organization  and  equipment  will  be  taken  up  later. 
A  word  must  also  be  said  of  other  departments  which 
are  not  diagnostic  in  character.  Such  are  Depart- 
ments for  Hydro-therapy,  Electro-therapy,  Zander, 
Corrective  Gymnastics,  and  Massage.     These  Treat- 


88  DISPENSARIES 

ment  Departments  raise  no  fundamental  problems  of 
medical  organization. 

Given  a  number  of  clinical  departments,  consider 
their  medical  staff  and  internal  organization.  The 
first  general  principle  which  should  apply,  to  Dispen- 
saries as  to  hospitals  and  all  similar  institutions,  is 
that  the  medical  staff  should  be  appointed  by  the 
governing  body  of  the  institution — usually  the  Board 
of  Trustees.  The  chief  of  each  department  should 
nominate  all  assistants,  but  the  acceptance  or  rejec- 
tion of  all  nominations,  as  well  as  the  power  to  initiate 
nominations  when  necessary,  should  rest  with  the 
Board.  Where  the  Board  is  composed  of  laymen,  as 
is  frequently  the  case,  a  Medical  Committee,  of  the 
staff  itself,  or  of  some  consultant  body,  should  be 
constituted  to  advise  the  Board  as  to  the  medical 
standing  of  candidates  or  nominees. 

Experience  has  shown  that  the  members  of  a 
medical  staff,  even  when  the  number  is  small,  may 
wisely  be  divided,  according  to  rank,  into  definite 
grades.  In  large  Dispensaries  three  will  be  found 
practically  necessary,  and  four  or  five  will  be  useful. 
Highest  is  the  rank  of  those  in  charge  of  clinics,  i.e., 
heads  of  departments.  Under  divided  services,  there 
may  of  course  be  two  or  more  ''heads"  to  one  depart- 
ment. The  title  usually  attached  to  this  rank  is 
*' Visiting  Physician,"  ''Physician-in-Chief,"  ''Physi- 
cian-in-Charge,"  or  simply  ''Physician,"  with  corre- 
sponding denominations  on  the  surgical  side.  Where 
the  Dispensary  is  an  out-patient  department  of  a 
hospital,  those  in  active  charge  of  out-patient  clinics 


ORGANIZATION  89 

sometimes  hold  merely  the  rank  of  assistants  or  junior 
assistants  in  the  hospital,  but  the  better  practice  is  to 
give  the  title  of  '^Physician"  or  ^^ Visiting  Physician" 
with  the  suffix,  ^Ho  Out-Patients,"  or  'Ho  the  Dis- 
pensary." 

The  second  rank  are  '^  Assistant  Physicians,"  or 
'^  Senior  Assistants,"  those  next  in  authority  to  the 
chief  of  a  department,  men  who  will  take  charge  in 
the  chief's  absence.  These  are  responsible  positions 
and  should  be  regarded  as  permanent  during  satis- 
factory service. 

Below  this  grade  are  men  who  receive  annual 
appointments,  renewable,  but  not  renewed  except 
when  desired  by  the  Chief  of  the  Department.  To 
them  the  title  of  '^  Junior  Assistant"  or  '^ Assistant  to 
the  Physician"  is  often  given.  Men  can  be  given 
valuable  opportunities  for  training  and  experience, 
by  appointment  to  this  grade,  without  committing 
the  institution  to  a  permanent  appointment,  which 
many  men  who  wish  merely  to  so  some  special  clinical 
work  for  a  few  years  would  not  desire. 

In  large  institutions,  there  is"  use  for  a  fourth  grade, 
sometimes  called,  '^  Graduate  Assistant,"  elsewhere 
'^ Unofficial  Assistant,"  etc.  These  appointments  are 
or  should  be  for  short  periods  only,  not  more  than  a 
year,  and  are  intended  to  provide  for  men  who  are 
being  tried  out,  or  who  wish  to  work  for  a  few  months 
only,  in  a  certain  department.  These  appointments 
are  usually  given  with  less  formality  than  the  other 
grades. 

Finally,  there  is  usually  place  for  a  group  of  men  as 


90  DISPENSARIES 

active  Consultants — men  who  have  served  their  time 
in  the  work,  or  who  are  eminent  in  the  local  profession. 
The  appointment  as  ''Consultants"  of  men  who  give 
nothing  but  their  names,  and  who  are  never  called 
in  to  consult,  should  be  discouraged. 

The  Trustees  should  make,  and  the  Superintendent 
should  enforce,  the  rule  that  no  medical  man  is  allowed 
to  do  any  work  in  any  clinic  without  some  form  of 
staff  appointment.  Medical  students,  graduate  or 
undergraduate,  coming  from  a  medical  college  to  an 
instructor  who  holds  an  appointment  on  the  staff  of 
the  institution,  should  be  the  sole  exception  to  this 
rule. 

In  former  years,  the  typical  internal  organization 
of  a  clinic  was  to  have  a  number  of  physicians  as 
''chiefs,"  serving  with  his  assistants,  if  any,  for  two 
or  three  months.  Thus  during  a  year  the  clinic  had 
from  four  to  six  different  sets  of  men  in  charge.  The 
nominal  advantage  of  such  a  service  is  that  it  gives 
many  men  a  chance  to  gain  medical  knowledge  from 
the  clinic.  This  is  much  more  than  counterbalanced 
by  the  diminution  in  quality  of  service  which  is  insep- 
arable from  such  frequent  changes.  Unification  of 
responsibility  under  a  single  head,  in  continuous 
charge  of  the  department,  is  the  ideal  type  of  organiza- 
tion— in  a  clinic  as  in  anything  else.  This  is  entirely 
compatible  with  opportunity  for  many  men  to  work 
and  learn  in  the  cHnic — as  many  as  with  the  other  plan. 

In  the  hospital  wards,  recent  years  have  witnessed 
the  same  passage  from  many  short  services  to  con- 
tinuous single-headed  services.     Sometimes  the  head 


ORGANIZATION  91 

of  a  hospital  service  is  ex-offido  head  of  the  corre- 
sponding clinic  in  the  out-patient  department.  But 
such  a  head  rarely  does  personal  work  with  out- 
patients. He  will  indeed  unify  the  medical  policy  of 
the  clinic  in  certain  broad  aspects,  and  this  is  a  great 
advantage;  but  no  absentee  government  by  the  hospi- 
tal chief  will  do  the  best  for  the  Dispensary.  If  he 
has  an  assistant  who  has  continuous  service  in  the 
out-patient,  the  situation  is  well  met.  In  practice, 
under  the  system  of  volunteer  medical  service,  it  may 
be  difficult  to  realize  the  ideal  of  an  out-patient  clinic 
under  a  single  head,  who  gives  personal  service  through- 
out the  year,  especially  if  the  Dispensary  is  not  con- 
nected with  a  medical  school  or  a  large  hospital. 
Every  effort  should  be  made  to  approximate  this 
ideal  as  nearly  as  can  be.  Two  chiefs,  each  on  service 
for  six  months,  are  six  times  better  than  four  ^' chiefs'^ 
each  serving  for  three  months.  As  few  heads  to  the 
department  as  possible,  as  long  services  as  possible:  has 
been  the  recent  and  the  right  motto. 

The  chief  of  a  department  has  two  problems:  first, 
the  determination  of  the  medical  policies  of  the  de- 
partment; and  second,  the  proper  execution  or  super- 
vision of  the  actual  diagnosis  and  treatment  of 
patients.  In  a  large  out-patient  clinic,  the  burden  of 
detailed,  personal  work  is  very  considerable.  It  is 
much  more  exacting  than  the  ward  work  of  the  hospi- 
tal. Consequently,  it  is  necessary  to  devise  some 
system  by  which  neither  the  chief  nor  any  one  assist- 
ant shall  bear  the  burden  for  too  long  a  period.  This 
need  has  sometimes  been  met  by  providing  a  chief 


92  DISPENSARIES 

with  four  assistants  who  serve,  each  for  three  months 
(with  junior  assistants,  if  the  cUnic  demands  it). 
The  chief  himself  visits  the  chnic,  either  daily  or  on 
specified  days  of  the  week.  Adequate  vacation  peri- 
ods must  be  allowed.  Sometimes  this  plan  has  been 
followed  with  two  first  assistants,  each  on  for  six 
months.  Another  form  of  division  is  made  by  having 
one  set  of  assistants  three  days  a  week,  and  another 
set  for  the  other  three  days;  each  group  coming  either 
throughout  the  year  or  for  six  months,  making  either 
two  or  four  sets  necessary.  Such  a  three-day-a-week 
service  works  very  well,  always  provided  that  both 
sets  of  the  three-day  service  are  responsible  to  a  single 
head.  Sometimes,  despite  [the  best  efforts,  patients 
will  come  on  the  wrong  day,  and  often  must  come 
because  of  conditions  which  require  immediate  treat- 
ment. This  is  likely  to  involve  the  two  sets  of  .the 
service  in  differences,  unless  there  is  a  single  chief  who 
enforces  co-ordination. 

3.  Outline  of  the  Administrative  Organization 

Certain  of  the  divisions  or  departments  of  work  in 
a  Dispensary  are  similar  to  those  of  any  institution, 
especially  to  a  hospital: — 

a.  Maintenance  of  building. 

b.  Purchasing  and  care  of  supplies. 

c.  Housekeeping    (steward's    department),    if   a    Dis- 

pensary is  separate  from  a  hospital,  and  provides 
residence  for  some  of  its  staff. 

d.  Laundry. 

e.  Compounding  and  dispensing  drugs. 


ORGANIZATION  93 

If  the  Dispensary  is  an  out-patient  department  of  a 
large  hospital,  all  of  the  above  divisions  will  be  repre- 
sented in  the  House  service,  and  the  officers  in  charge 
of  each  will  of  course  exercise  technical  supervision 
over  the  appropriate  departmental  duties  in  the 
Dispensary.  A  small  Dispensary,  separate  from  a 
hospital,  would  probably  have  its  laundry  done  outside 
and  would  have  no  one  live  in  the  building,  except 
perhaps  the  janitor;  the  purchasing  and  care  of  sup- 
plies might  take  a  little  of  the  time  of  a  nurse  or  some 
other  person. 

The  non-medical  professional  services  rendered  in 
a  Dispensary  require : — 

1.  General  executive  work  and  supervision. 

2.  Admission  and  registration  of  patients. 

3.  Nursing. 

4.  Social  service. 

5.  Clinic  management. 

6.  Clerical  service. 

In  a  large  Dispensary  each  of  these  divisions  may 
have  its  chief. 

The  management  of  clinics,  as  has  been  pointed 
out  in  the  preceding  chapter,  involves  the  super- 
vision of  the  general  clinic  administration,  the  attend- 
ance of  the  Staff,  the  making  and  handling  of  the 
records,  the  personal  treatment  of  patients,  the  follow- 
up  system,  etc.  This  supervision  should  either  be 
performed  by  the  Superintendent  of  the  Dispensary 
personally,  or  with  the  aid  of  an  assistant  who  pursues 
certain    details.     In    a    Dispensary    or    out-patient 


94  DISPENSARIES 

department  of  moderate  size,  the  duties  of  the  Super- 
visor of  Clinics,  in  so  far  as  not  performed  by  the 
Superintendent  of  the  Dispensary,  may  be  assigned 
to  one  of  the  other  heads  of  departments,  either  the 
Head  Worker  of  the  Social  Service  Department,  or 
the  Head  Nurse.  Tact,  good  judgment  and  a  sense 
for  good  organization  are  required,  as  well  as  executive 
ability  in  details. 

Clerical  service  should  be  organized  as  one  bureau 
for  the  entire  institution  so  far  as  stenographic  work 
is  concerned.  The  clinical  clerk,  who  makes  memo- 
randa on  records  in  the  clinic,  attends  to  the  follow-up 
system,  to  keeping  patients  in  order,  etc.,  is  really  an 
assistant  in  clinic  management.  The  distribution  and 
care  of  the  medical  records  may  either  be  under  the 
Registrar  or  the  Chief  Clerk. 

The  general  executive  work  and  supervision  is,  of 
course,  the  duty  of  the  Dispensary  Superintendent, 
who,  in  the  out-patient  department  of  a  large  hospital, 
would  usually  be  an  Assistant  Superintendent  of  the 
Hospital. 

In  all  out-patient  departments  there  should  be 
carefully  held  in  mind  and  rigidly  applied  the  prin- 
ciple of  ''Line  and  Staff"  organization.  The  chief  of 
a  hospital  bureau,  such  as  a  Superintendent  of  Nurses, 
the  head  of  the  Social  Service  Department,  etc.,  should 
exercise  professional  supervision  over  the  technical 
work  of  nursing  or  social  service,  and  will  thus  see 
that  the  quality  of  the  technique  is  maintained.  This 
is  the  staff  function  of  these  chiefs.  But  orders  issued 
to  any  of  the  employees  of  the  Dispensary  must  come 


ORGANIZATION  95 

through  the  Superintendent  of  the  Dispensary,  who 
is  the  head  of  the  ''line."  If  this  rule  is  followed,  the 
Dispensary  will  be  maintained  as  a  really  unified  and 
effective  working  organization.  If,  however,  the 
head  of  a  hospital  bureau  is  permitted  to  issue  orders 
in  the  Dispensary  directly,  without  going  through  the 
Superintendent  of  the  Dispensary  or  Out-Patient 
Department,  the  unity  of  the  dispensary  organization 
will  suffer  and  its  effectiveness  in  proportion. 

It  should  go  without  saying,  that  the  Superintendent 
of  the  Dispensary  should  be  permanent  in  office  and 
not  be  a  rotating  official  chosen  in  order  from  the 
Assistant  Superintendents  of  a  large  hospital.  A 
dispensary  superintendent  needs  certain  qualities 
not  always  connected  with  institutional  work.  In 
particular  he  needs  to  possess  two  qualities: 

First:  ability  to  deal  with  all  kinds  of  people  wisely  and 
tactfully; 

Second:  ability  to  see  the  Dispensary's  problems  from 
the  standpoint  of  the  community,  not  merely  from  that  of 
an  institution. 

Different  sizes  of  Dispensaries  of  course  require 
adaptation  in  the  administrative  organization  just 
described.  The  purchasing  of  supplies  in  a  Dispensary 
not  connected  with  a  hospital  may  be  in  charge  of  the 
head  nurse  or  the  pharmacist.  The  superintendent 
may,  in  a  small  Dispensary,  act  as  admitting  officer, 
as  registrar,  with  a  clerk  to  assist  him;  the  superin- 
tendent may  directly  oversee  clinical  management  or 
may  delegate  much  of  that  to  the  head  worker  of  the 
Social   Service   Department   or  to   the  head  nurse. 


96  DISPENSARIES 

The  admission  of  patients  has  not  infrequently  been 
assigned  to  social  service.  First  of  all  it  is  important 
to  have  clearly  in  mind  the  various  functions  which 
must  be  performed.  These  are  alike  in  all  Dispen- 
saries which  treat  general  diseases.  If  a  proper 
analysis  of  functions  is  made,  then  the  distribution  of 
the  functions  among  the  available  personnel  in  an 
organization  of  a  given  size  will  not  be  difficult.  For 
example,  in  a  little  Dispensary  receiving  fifty  visits  a 
day,  a  single  nurse,  one  social  worker  and  a  clerk  may 
constitute  the  non-medical  staff  (besides  the  janitor, 
cleaner,  etc.).  One  person  must,  however,  be  the 
head  executive.  Which  shall  it  be?  Generally 
speaking,  a  woman  with  a  broad  social  training  will 
be  found  the  most  desirable  head,  whether  her  routine 
duties  in  the  Dispensary  are  those  of  a  nurse  or  a  social 
worker. 

4.  Co-ordinating  All  Factors 

The  medical  staff,  while  organized  for  working 
purposes  into  its  units  as  clinical  departments,  must, 
for  the  broader  purposes  of  the  dispensary  manage- 
ment, be  made  into  a  larger  unit.  Formerly  it  was 
often  the  custom  to  have  an  organization  of  all  the 
physicians,  assistant  physicians,  etc.,  with  their  own 
president,  secretary  and  other  officers  and  committees. 
This  plan  has  the  advantage  of  getting  everybody 
together,  and  it  also  provides  a  means  for  social  and 
medical  meetings  of  the  whole  staff.  But  it  has  the 
serious  disadvantage,  with  a  large  staff,  that  the 
organization  is  cumbersome.     The  mixture  of  chiefs 


ORGANIZATION  97 

and  assistants,  the  latter  usually  in  numerical  majority, 
at  meetings,  prevents  the  serious  discussion  of  many 
problems;  and  the  elections  and  appointments  are 
likely  to  be  influenced  by  considerations  other  than 
the  specific  work  which  the  ofiicials  or  committees 
are  to  do.  A  much  better  form  of  medical  organiza- 
tion for  a  large  staff  is  to  recognize  the  basal  principle, 
viz.,  that  the  heads  of  departments  are  those  upon 
whom  the  responsibility  for  the  medical  work  of  the 
Dispensary  really  rests.  The  heads  of  the  depart- 
ments should  therefore  form  the  essential  part  of 
the  staff  organization,  if  this  organization  is  really  to 
play  a  responsible  part  in  the  management  of  the 
Dispensary.  The  heads  of  the  departments  meeting 
annually,  or  as  necessary,  in  council,  furnish  a  responsi- 
ble body  and  will  select  any  needed  committees  or 
aid  the  trustees  in  selecting  them. 

When  there  are  ten  or  more  chiefs  of  departments, 
a  working  or  executive  committee  formed  of  or  by  the 
heads  of  departments  will  be  desirable,  and  this  should 
rarely  exceed  five  members.  In  some  institutions 
such  a  committee,  with  the  superintendent,  forms 
practically  the  administrative  body  of  the  institution, 
the  trustees  acting  only  on  major  questions  of  policy, 
appointments  and  finance.  But  it  is  unfortunate 
thus  to  cut  off  the  trustees  from  the  real  work  of  the 
Dispensary.  The  ultimately  responsible  body,  the 
trustees,  should  regard  it  as  part  of  their  duty  to  come 
into  active  touch  with  the  administration.  This 
may  be  by  means  of  joint  meetings  between  some  of 
the  medical  committee  and  the  trustees,  or  a  com- 


.  98  DISPENSARIES 

mittee  of  the  trustees.  In  either  case  the  Superin- 
tendent should  be  a  member  of  the  group.* 

The  correlation  of  the  Dispensary  with  other 
agencies  in  the  community  is  also  a  function  of  its 
organization.  The  relationship  to  the  medical  agen- 
/cies,  the  hospitals,  the  convalescent  homes,  the 
department  of  health,  etc.,  usually  remain  undefined. 
A  definite  series  of  understandings  can,  however,  be 
worked  out  by  which  a  Dispensary  which  does  not 
possess  a  hospital,  may  facilitate  admission  of  its 
patients  to  hospitals  or  convalescent  homes  and  se- 
cure the  needed  follow-up  data,  therefrom.  Suitable 
understandings  with  the  health  department  also  will 
promote  effective  working  relations.  It  is  also  desira- 
ble to  have  an  understanding  with  the  other  Dis- 
pensaries in  the  community,  as  to  policy  regarding 
the  admission  of  patients  and  the  disposition  of 
patients  who  have  been  treated  recently  at  one  of  the 
other  institutions. 

The  relationships  of  the  Dispensary  to  charitable 
and  social  agencies  should  be  worked  out  through  the 
Social  Service  Department.  As  will  be  seen  in  Chap- 
ter VIII,  the  modes  by  which  non-medical  agencies 
may  best  use  the  Dispensary  in  behalf  of  their  bene- 
ficiaries, and  the  modes  by  which  the  Dispensary  can 
best  use  outside  welfare  agencies  in  solving  the  social 
problems  of  its  patients,  are  both  capable  of  formu- 
lation in  working  agreements  between  the  Dispensary 
and  the  outside  welfare  societies. 

In  the  out-patient  department  of  a  large  general 

♦See  Appendix,  pages  421  and  425. 


ORGANIZATION  99 

hospital,  one  of  the  final  problems  of  organization  is 
how  the  Dispensary  shall  stand  on  its  own  feet.  How 
does  the  scheme  of  organization  of  the  medical  staff 
and  the  administrative  officials  and  employees,  as 
above  described,  apply  to  the  problem  of  an  out- 
patient department  of  a  great  hospital?  Here  again, 
if  we  follow  fundamental  principles  carefully,  the 
answer  will  not  be  difficult.  The  fundamental  prin- 
ciples are: 

1.  In  making  up  judgment  upon  policies,  all  factors 
affected  by  the  policy  should  have  representation. 

2.  Those  directly  responsible  for  the  dispensary  work, 
should  be  immediately  responsible  for  the  dispensary  man- 
agement. 

These  statements  mean,  in  practice: — 

1.  The  medical  staff  of  the  Dispensary  (out-patient  de- 
partment), whatever  their  positions  or  rank  in  the  institu- 
tion as  a  whole,  should  be  organized  as  a  dispensary  staff  or 
have  a  committee  of  their  number  serving  as  a  medical 
committee  for  the  Dispensary.  In  other  words,  the  heads 
of  departments  who  are  in  active  service  as  chiefs  of  clinics 
in  the  out-patient  department,  should  be  treated  as  heads 
of  the  departments  in  the  Dispensary  for  the  purpose  of 
forming  a  Dispensary  Medical  Committee.  If  the  staff  of 
the  hospital  wards  possesses  a  responsible  medical  com- 
mittee, as  it  should,  the  Dispensary  Medical  Committee 
will  of  course  be  subordinate  in  matters  of  general  policy  to 
the  committee  of  the  House  staff.  But  no  activity  or 
interest  on  the  part  of  House  men  who  do  not  themselves 
have  personal  contact  with  the  problems  of  the  Dispensary, 
will  supply  the  place,  in  guiding  administration  and  fur- 


100  DISPENSARIES 

nishing  constructive  criticism,  of  the  men  who  are  doing 
the  actual  out-patient  work. 

2.  The  Assistant  Superintendent  of  the  hospital,  who  is 
assigned  to  the  charge  of  the  Dispensary,  should  have 
direct  relations  to  the  Dispensary  Medical  Committee. 
Whenever  important  dispensary  problems  are  under  con- 
sideration, he  should  also  have  opportunity  to  confer  with 
the  Superintendent  of  the  Hospital  and  with  the  medical 
committee  of  the  House  staff. 

3.  The  Trustees,  through  some  of  their  members,  or  a 
special  committee,  should  be  in  touch  with  the  dispensary 
Medical  Committee  and  with  the  dispensary  Superintend- 
ent, either  through  periodical  joint  meetings  or  some  other 
mode  of  procedure. 

4.  The  executive  officers  of  the  departments  of  the  hospi- 
tal, such  as  the  Superintendent  of  Nurses,  the  head  of  the 
Social  Service  Department,  etc.,  should  act  as  staff  advisers 
to  the  Superintendent  of  the  Dispensary  according  to  the 
method  previously  described. 

5.  The  key  to  successful  guidance  of  policy  and  administra- 
tion in  any  organization  is  to  bring  together  those  who  know 
the  facts  on  which  judgment  should  be  based,  with  those  who 
need  to  know  the  facts  in  order  to  frame  judgment. 

To  do  this,  in  the  Dispensary  or  Out-Patient  Department, 
is  the  duty  of  its  Superintendent.  He  should  not  only  be 
expected  to  give  his  own  views  and  the  facts  in  his  possession 
to  the  officials  or  committees  above  him,  but  also  to  secure 
from  the  heads  of  medical  or  executive  departments  in  the 
Dispensary  the  facts  which  they  alone  know.  Personal 
conferences  between  such  individuals  with  the  responsible 
committees  and  officials  are  often  valuable.  There  is  no 
stimulant  like  first-hand  facts. 


SOCIAL  SERVICE  101 


CHAPTER   VIII 
SOCIAL   SERVICE 

Social  Service  in  a  hospital  or  Dispensary  means 
assistance  to  the  physicians  in  the  education  of  pa- 
tients and  the  control  of  their  environment. 

It  means  '^assistance  to  the  physicians/^  for  it  is 
medical  social  service.  The  function  of  the  hospital 
or  Dispensary  is  medical  and  it  is  in  pursuit  of  medical 
efficiency  that  the  institution  enters  into  social  service. 
Conditions  in  the  patient^s  environment  often  need  to 
be  ascertained  in  order  to  confirm  or  suggest  a  diagno- 
sis. Conditions  of  the  patient^ s  environment  as  well 
as  his  state  of  mind — his  ignorance,  his  prejudices — 
need  to  be  altered  or  controlled  in  order  to  render 
efficient  treatment  possible.  To  ascertain  facts  con- 
cerning the  patient's  personality  and  environment  and 
to  apply  this  knowledge  so  as  to  help  in  achieving 
medical  results,  is  the  scope  and  function  of  medical 
social  service  in  the  Dispensary. 

The  pioneer  Social  Service  Department  was  founded 
in  this  country  at  the  Massachusetts  General  Hospital, 
in  1906,  by  Dr.  Richard  C.  Cabot.  It  began  in  the 
Out-Patient  Department.  Medical  social  service  has 
been  extended  into  the  wards  in  many  hospitals.  In 
some  institutions  it  began  therein.  But  in  large  part, 
it  has  remained  a  feature  of  the  dispensary  work.  The 
special  technique  of  social  service  in  hospitals  and 


102  DISPENSARIES 

dispensaries  has  been  well  treated  in  the  book  by- 
Miss  Ida  M.  Cannon  and  has  so  frequently  been  dis- 
cussed in  the  proceedings  of  the  National  Conference 
of  Charities  and  elsewhere  during  recent  years,  that 
it  is  unnecessary  to  enter  into  details  here.  Our  pur- 
pose in  this  Chapter  will  therefore  be  to  discuss 

(1)  The  kinds  of  work  undertaken  by  social  service  in  a 
Dispensary. 

(2)  The  organization  of  the  social  service  work. 

(3)  Selecting  and  training  the  working  staff  of  a  Social 
Service  Department. 

I.  Kinds  of  Medical  Social  Work 

The  kinds  are  infinitely  varied.  Every  conceivable 
human  problem  is  faced  in  the  course  of  a  year  in  the 
Social  Service  Department  of  a  large  Dispensary.  A 
woman  needs  an  operation — but  at  home  are  four 
young  children,  and  the  father  earns  but  $12  a  week. 
The  mother  can  neither  leave  her  little  ones,  nor  afford 
a  servant.  The  doctor  may  make  his  diagnosis  and 
advise  the  operation,  but  unless  the  social  worker 
finds  out  the  woman's  home  situation  and  secures  a 
friend  or  relative  to  act  as  caretaker,  or  a  charitable 
agency  which  will  hire  one  if  necessary,  the  woman  will 
not  go  to  the  hospital  for  what  she  needs.  A  man 
comes  with  syphilis.  His  wife  and  children  ought  to 
be  examined,  and  perhaps  when  they  meet  the  doctor 
the  family  situation  which  faces  the  physician  and  the 
social  worker  will  require  the  wisdom  of  Solomon  to 
solve.  A  mother  brings  a  sick  baby  wrapped  in  many 
clothes  and  fed  on  condensed  milk.     Ignorance  and 


SOCIAL  SERVICE  103 

not  lack  of  income  must  be  patiently  wrestled  with. 
The  variety  of  these  problems  can  be  best  shown  by 
listing  the  actual  problems  faced  in  326  consecutive 
cases  taken  up  by  the  Social  Service  Department  of  a 
large  Dispensary  during  six  consecutive  months : 

Assuring  advised  hospital  care 50 

Arranging  for  convalescent  care 34 

Procuring  institutional  care 16 

Aiding  in  diagnosis  by  investigating  past  medical-social  history ....  36 

Securing  necessary  after-care  for  children  discharged  from  hospital  46 

Arranging  and  advising  for  special  diet 4 

Supervising  hygiene 33 

Adapting  working  conditions  to  patient's  physical  limitations  ....  5 
Arranging  for  examination  of  persons  exposed  to  a  contagious 

disease 40 

Social  care  for  unmarried  mothers 10 

Securing  care  for  neglected  children 9 

Securing  and  supervising  the  wearing  of  apparatus 12 

Arranging  instalment  terms  for  expensive  medical  treatment ....  7 

Arranging  for  material  relief 13 

Making  special  school  arrangements  for  cardiac  and  chorea  cases  . .  1 

Securing  employment 1 

Assuring  advised  dental  care 1 

Arranging  for  special  treatment  in  other  Out-Patient  Departments  3 

Supervising  attendance  at  clinic 4 

Straightening  out  financial  tangle 1 

Total 326 

An  examination  of  this  list  brings  out  at  once  certain 
points  of  interest: 

(1)  Contrary  to  a  prevalent  impression,  the  presence  of 
acute  poverty  is  not  the  most  frequent  cause  for  taking  up  a 
social  service  case  in  a  hospital  or  Dispensary.  Some  of  the 
problems  in  the  preceding  list  may  occur  in  families  of  any 
grade  of  income.  Many  will  occur  in  families  of  small 
income,  well  above  the  poverty  line. 

(2)  Education,  rather  than  relief,  is  the  dominating 
activity  of  the  dispensary  social  worker  in  relation  to  the 
patient. 

8 


104  DISPENSARIES 

(3)  Utilization  or  organization  of  community  resources  to 
achieve  results  for  a  patient  is  the  dominating  activity  of  the 
dispensary  social  worker  in  relation  to  the  community.  The 
Social  Service  Department  of  a  Dispensary  serves  as  a 
clearing-house  through  which  the  charitable,  educational, 
industrial  and  civic  resources  of  the  community  are. made 
useful  to  help  in  achieving  medical  results  for  various  pa- 
tients. The  greater  the  extent  to  which  the  Social  Service 
Department  can  utilize  other  agencies  to  perform  these 
services,  the  more  economical  and  the  more  efficient  is  the 
Social  Service  Department  in  the  organized  welfare  work  of 
its  community. 

It  will  readily  be  seen  that  the  work  to  be  done  for 
one  patient  may  be  comparatively  easy  and  brief.  A 
little  explanation  tactfully  given  in  the  Dispensary 
itself  may  be  sufficient  to  straighten  out  a  difficulty  for 
one  patient.  For  another  patient,  weeks  of  work  with 
many  home  visits,  conferences  with  other  agencies, 
talks  with  doctors,  telephone  calls,  letters,  etc.,  may 
be  required.  Assuring  the  performance  of  a  needed 
operation  may  require  only  a  few  minutes'  talk  with 
the  patient,  a  letter  to  the  relatives  and  a  telephone 
call  to  a  hospital,  while  the  social  work  required  for  a 
complex  neurological  case  might  be  twenty  or  fifty 
times  this  amount.  Social  service  cases  have  some- 
times been  classified  according  to  the  relative  quantity 
of  work  required;  the  so-called  ^' clinical'^  or  ^'slight 
service  cases"  having  been  contrasted  with  the  so- 
called  '' intensive"  cases.  The  idea  has  been  that  the 
former  group  could  be  handled  by  the  social  worker 
chiefly  or  entirely  within  the  clinic  or  within  the  dis- 


SOCIAL  SERVICE  105 

pensary  building,  while  the  ^^ intensive  cases"  required 
outside  visits.  This  distinction,  however,  is  only  one 
of  degree  and  cannot  be  sharply  drawn.  It  is  of  no 
fundamental  importance. 

The  fundamental  job  of  the  medical  social  worker  is 
social  analysis  or  in  the  more  suggestive  medical 
terminology — social  diagnosis.  The  task  of  a  Social 
Service  Department  has  nowhere  been  more  distinctly 
formulated  than  by  Mrs.  Elizabeth  Richards  Day  in 
three  sentences  written  six  years  ago. 

''  The  medical-social  worker  is  essentially  the  diagnostician 
of  the  patient's  social  needs.  To  make  this  diagnosis  she 
must  have  the  knowledge  which  investigation  yields.  To 
meet  these  social  needs  she  calls  upon  those  agencies  in  the 
community  which  are  best  able  to  cope  with  the  special 
problem  involved." 

''There  are  many  instances,"  Mrs.  Day  writes  further, 
"where  the  medical  social  worker  is  the  most  appropriate 
agent  for  dealing  with  the  particular  problem,  teaching 
hygiene,  arranging  for  hospital,  sanitorium  and  convalescent 
care.  Is  it,  however,  a  child  to  be  boarded  in  the  country? 
A  children's  society  has  the  equipment  to  accomplish  this 
best.  Is  it  poverty  which  makes  it  impossible  to  buy  the 
extra  diet  or  surgical  appliance?  A  relief  agency  will  act 
wisely  here.  Is  it  a  mother  to  be  instructed  in  the  feeding  of 
her  delicate  baby?  A  nurse  from  a  milk  station  will  teach 
her.  Calling  on  these  societies  for  help  does  not  mean  that 
the  medical  social  worker's  responsibility  is  over.  On  the 
contrary  it  may  be  just  beginning.  She  must  see  that  the 
patient  returns  regularly  for  treatment  at  the  Dispensary. 
There  is  constant  reporting  back  and  forth  between  the 
societies  co-operating  in  the  care  of  the  patient." 


106  DISPENSARIES 

In  a  large  city  with  many  and  well  developed  socie- 
ties for  relief,  child-caring,  education,  etc.,  the  dis- 
pensary social  worker's  task  in  carrying  out  treatment 
consists  very  largely  in  utilizing  these  agencies.  In  a 
small  community  or  one  with  poorly  developed  welfare 
agencies,  the  medical  social  worker  may  have  to  go 
considerably  further  in  performing  various  outside 
functions  herself,  but  so  far  as  possible  she  should  aid 
the  under-developed  community  to  establish  agencies 
rather  than  attach  to  the  medical  institution  distinctly 
outside  social  functions. 

In  a  number  of  cities  and  not  a  few  small  towns,  the 
establishment  of  a  Dispensary  came  about  because  a 
charitable  society  saw  the  need  of  one.  A  charity 
organization  society  perceives  the  large  proportion  of 
poverty  which  is  caused  by  illness,  and  the  hopeless- 
ness of  the  effort  to  relieve  such  need  unless  adequate 
medical  care  be  secured.  A  Dispensary  started  under 
such  auspices  usually  has  its  Social  Service  Depart- 
ment in  the  workers  of  the  society  itself.  Cases  also 
exist  in  which  an  old-established  Dispensary  has  asked 
a  charitable  society  of  the  city  to  do  its  medical-social 
work  and  to  assign  one  or  more  workers  to  the  clinics. 
These  relationships  should  not  obscure  the  essential 
distinguishing  quality  of  the  Social  Service  Depart- 
ment :  that  it  is  medical  in  its  reason  for  being.  In  the 
future,  we  are  likely  to  see  the  development  of  public 
health  work  along  district  lines.  Thorough  organiza- 
tion of  each  section  of  a  community  is  to  be  expected ; 
a  pubUc  Health  Center  with  its  visiting  nurses  may  be 
looked  for  in  each  district.     These  nurses  will  acquire 


SOCIAL  SERVICE  107 

familiarity  with  the  conditions  of  very  many  of  the 
families  therein,  and  invaluable  personal  influence. 
The  Health  Centers  will  serve  in  many  ways  to  relieve 
large  central  hospitals  and  dispensaries  from  much 
detailed  case-work  in  the  homes  which  is  now  neces- 
sary. There  will  remain  cases  of  so  specialized  a  na- 
ture that  the  specialist  worker  from  the  institution 
must  deal  with  them.  But  we  may  in  general  look  for 
a  slow  tendency,  for  the  workers  of  the  Social  Service 
Department  to  specialize  more  and  more  in  particular 
medical  fields,  to  limit  their  work  more  and  more  to 
medical-social  diagnosis,  and  to  carry  out  social  treat- 
ment only  in  so  far  as  welfare  agencies  or  district 
public-health  agencies  are  unable  to  do  it  for  them. 

2.  Organization  of  a  Social  Service  Department 

In  a  small  Dispensary  "  Si  Social  Service  Depart- 
ment "  might  have  one  worker.  In  a  large  Dispensary 
there  might  be  twenty.  In  either  case  the  head  of  the 
Department  should  be  responsible  to  the  Superin- 
tendent of  the  Dispensary  (or  hospital),  in  the  same 
manner  as  the  head  of  any  other  department.  In 
many  hospitals  and  dispensaries  there  exists  a  Social 
Service  Committee.  Sometimes  this  is  a  section  of  the 
Ladies'  Aid  Society  of  the  institution.  Elsewhere 
there  is  a  special  committee  which  may  include  mem- 
bers of  the  Board  of  Trustees  of  the  Hospital,  some- 
times members  of  the  Medical  Staff,  and  of  the  Ladies' 
Board.  The  constituency  may  be  limited  to  only  one 
or  two  of  these  groups  or  may  be  still  more  widely 
varied.     On  any  such  committee  the  Superintendent 


108  DISPENSARIES 

should  be  a  member.  With  a  Social  Service  Commit- 
tee, as  with  any  similar  body  in  an  institution,  it  is 
important  that  the  duties  should  be  advisory  and  not 
include  administrative  details  for  which  the  profes- 
sional staff  should  be  responsible. 

In  practice,  the  Social  Service  Committees  are 
usually  of  much  assistance  in  a  financial  way.  They 
are  of  additional  value  because  contact  with  the  social 
work  informs  their  members  personally  about  the 
patients  and  also  raises  thought-provoking  problems 
of  relationship  between  the  institution  and  the  com- 
munity. Such  a  Social  Service  Committee  is  there- 
fore usually  desirable  both  from  the  standpoint  of 
finance  and  of  general  utility.  The  Head  Worker  of 
the  Social  Service  Department  should  be  in  the  same 
general  relation  to  the  Social  Service  Committee  as 
the  Superintendent  of  the  Hospital  is  to  the  Board  of 
Trustees.  Ordinarily  the  Board  of  Trustees  will 
wisely  expect  the  Social  Service  Committee  to  make  to 
the  Board  recommendations  on  questions  of  policy  or 
finance,  except  when  power  has  been  clearly  delegated 
to  the  Committee. 

The  physician  who  has  charge  of  a  case  must,  of 
course,  retain  the  full  medical  responsibility  for  it 
and  give  to  the  social  worker  the  medical  indications  or 
directions.  In  the  social  work  appear  many  problems 
about  which  the  physician  is  often  little  informed. 
Therefore  it  is  important  that  the  dispensary  social 
worker  have  a  well-recognized  right  of  initiative,  pro- 
vided always  that  she  reports  her  findings  of  facts  and 
her   suggestions   to   the   physician.     No   plan   for   a 


SOCIAL   SERVICE  109 

patient  should  be  adopted  unless  it  is  based  upon  the 
medical  opinion  and  the  social  facts  jointly,  as  rep- 
resented by  the  physician  and  the  social  worker 
together. 

New  Social  Service  Departments  have  often  grown 
out  of  the  interest  of  a  particular  person  or  of  a  physi- 
cian of  the  Staff.  The  first  worker  in  such  a  Depart- 
ment naturally  starts  in  the  clinic  in  which  this  person 
is  most  interested,  but  as  such  a  Department  grows, 
it  must  decide  where  and  how  to  assign  further  work- 
ers. In  a  Department  of  five,  ten  or  twenty  social 
workers,  this  question  of  assignment  and  organization 
is  of  the  greatest  importance.  When  social  service 
starts  in  an  institution,  the  physicians  of  the  Staff 
usually  begin  by  referring  to  the  social  workers,  cases 
picked  out  because  of  some  outstanding  or  superfici- 
ally apparent  human  need.  The  under-clothed  child, 
the  over-burdened  widow,  illustrate  this  type  of 
selection.  But  as  soon  as  the  physician  sees  that  the 
real  value  of  the  social  service  is  medical  and  that  its 
function  is  to  aid  in  achieving  medical  results,  his 
selection  of  cases  changes  and  broadens.  The  demand 
for  taking  social  service  cases  always  outruns  the 
money  available  for  providing  workers.  Selection  is 
necessary.  What  cases  are  the  most  appealing?  the 
most  important?  How  many  cases  of  certain  types 
can  a  specified  number  of  workers  handle?  Is  it  more 
worth  while  for  them  to  deal  with  a  large  number  of 
cases,  or  with  a  smaller  number  of  cases  requiring  on 
the  average  much  more  individual  time? 

The  special  interests  of  particular  physicians  or  the 


no  DISPENSARIES 

chance  preferences  of  contributors,  may  supply  a 
temporary  answer  to  these  questions.  But  such  con- 
siderations should  not  determine  them  finally.  The 
questions  can  really  be  answered  by  facts.  Actual 
study  of  different  clinics  and  of  different  medical 
types  of  cases,  reveals  relative  need  for  social  service. 
A  children's  clinic  or  a  neurological  clinic  usually 
presents  a  larger  proportion  of  cases  needing  social 
service  than  does  a  dental  or  an  eye  clinic.  A  survey 
by  a  trained  social  worker  can  be  made  of  the  social 
problems  presented  by  the  patients  in  a  clinic.  On 
the  basis  of  the  facts  secured,  the  social  work  can  be 
intelligently  planned  for  that  department  or  for  all  the 
departments  actually  surveyed.  Such  studies  are 
the  only  scientific  basis  for  deciding  the  places  where 
social  work  is  most  needed  within  an  institution,  and 
the  kinds  of  cases  with  which  it  can  accomplish  the 
best  results  in  proportion  to  the  effort  expended.  The 
simple  methods  used  in  such  surveys  are  described  in 
Chapter  XV,  on  Efficiency  Tests. 

When  Social  Service  Departments  began,  the  cases 
usually  came  to  the  social  workers  by  reference  from 
the  physician.  The  social  workers  had  their  office 
somewhere  in  the  building  and  the  patients  were  sent 
to  them  by  the  physicians.  A  great  step  was  taken 
when  in  1911  the  social  workers  of  the  Boston  Dis- 
pensary were  assigned  directly  to  the  clinics.  There, 
being  in  first-hand  contact  with  the  patients,  they 
secured  ''social  histories,"  were  able  to  discuss  cases 
with  the  physicians  from  the  beginning  and  at  once 
greatly  increased  the  power  of  the  social  workers,  after 


SOCIAL  SERVICE  111 

obtaining  facts,  to  exercise  initiative.  The  convenience 
and  value  of  social  service  to  the  physician  was  en- 
hanced. The  plan  of  assigning  workers  to  clinics  has 
spread  widely  among  the  Social  Service  Departments 
of  the  United  States. 

In  Departments  thus  organized,  with  social  workers 
assigned  to  various  clinics,  it  is  usually  necessary  to 
retain  one  or  more  workers  who  can  take  cases  from 
clinics  to  which  there  is  no  social  worker  specially 
assigned,  or  in  which  the  total  amount  of  social  service 
required  would  not  be  sufficient  to  require  all  of  one 
worker's  time. 

The  disadvantage  of  the  assignment  of  workers  to 
clinics  is  that  the  social  worker  is  likely  to  become 
involved  in  the  executive  management  of  the  clinic, 
or  in  clerical  duties,  to  an  extent  which  may  seriously 
diminish  the  time  which  she  can  devote  to  the  work  for 
which  she  is  specially  trained — social  service.  Getting 
patients  to  the  doctor  in  the  proper  order,  answering 
the  numerous  questions  which  arise  from  visitors, 
patients,  etc.,  attending  to  records,  etc.,  are  all  useful 
functions,  but  do  not  belong  to  a  member  of  the  Social 
Service  Department  as  such.  The  Dispensary  may 
not  be  able  to  provide  a  clinic  with  a  special  clerk,  a 
clinic  manager,  or  other  person  who  can  assume  execu- 
tive duties.  In  this  case  the  Dispensary  will  have  to 
decide  whether  the  social  worker  had  better  perform 
these  functions  or  not,  but  it  must  be  clearly  recognized 
that  if  she  does,  the  amount  of  social  service  which 
she  can  do  will  be  limited. 

The  alternative,  however,  is  not  to  go  back  to  the  old 


112  DISPENSARIES 

system  under  which  social  workers  were  cut  off  from 
direct  contact  with  patients  until  after  the  patients 
had  been  referred  by  the  physicians.     The  alternative 
is  the  placing  of  social  workers  in  clinics  under  condi- 
tions which  shall  not  tie  them  down  to  executive  or 
clerical  duties.     The  development  of  medical  social 
service  has  shown  that  the  problems  which  must  be 
dealt  with  are  varied  and  highly  specialized;  hence  that 
there  will  be  a  gain  in  efficiency  if  the  members  of  the 
Staff  of  a  large  Social  Service  Department  specialize 
also.     Each  worker  may  be  confined  to  a  single  type 
of  case  or  a  group  of  closely  related  types — e.g.,  chil- 
dren's cases,  industrial  cases,  venereal  disease,  neurolog- 
ical cases,  eye  cases,  etc.     Each  represents  a  group 
in  which  especial  attention  will  bring  the  reward  of 
special  skill.     Assignment   of  workers  according  to 
lines  of  such  practical  specialization  coincides  nearly 
but  not  quite  with  assignment  of  workers  to  clinics. 
A  large  medical  clinic  includes  certain  marked  types 
of  cases,  such  as  the  gastro-intestinal,  the  cardiac,  the 
industrial,    and    numerous    others.     Each    presents 
peculiar  social  as  well  as  medical  problems  and  if  the 
clinic  and  the  number  of  social  workers  are  large 
enough,  the  time  of  at  least  one  worker  can  be  devoted 
to  each  type  with  advantage.     The  tendency  in  future 
Social  Service  Departments  will  more  and  more  tend 
to  follow  the  tendency  of  medicine  itself  in  developing 
specialties.     Such  a  degree  of  specialization  faces  us 
with  the  risk  of  losing  sight  of  cases  in  the  general 
clinic  which  do  not  fall  into  any  one  of  the  groups  to 
which  special  workers  are  assigned.     The  correctives 


SOCIAL  SERVICE  113 

for  the  dangers  of  over-specialization  in  the  case  of 
social  service  are: — 

(1)  The  retention  of  a  certain  proportion  of  social  workers 
who  are  seeking,  and  are  ready  to  take  up,  cases  which  do 
not  fall  into  any  one  of  the  specialized  fields. 

(2)  The  free  and  frequent  use  of  the  Survey  Method — 
looking  over  the  human  material  of  a  clinic  at  periodic 
intervals  (and  of  the  Dispensary  as  a  whole  less  frequently) ; 
in  order  to  classify  and  re-classify  the  social  needs  apparent, 
arrange  them  in  order  of  relative  magnitude  and  importance, 
and  adjust  the  assignment  of  social  workers  from  time  to 
time  so  as  to  accomplish  the  most  with  the  available  staff.* 

The  assignment  of  social  workers  will  of  course  be 
affected  not  only  by  the  number  or  apparent  impor- 
tance of  the  cases  presenting  certain  social  needs,  but 
also  by  the  practical  possibilities  of  attaining  satis- 
factory results  with  the  cases.  One  fundamental  con- 
dition is  good  medical  work.  An  uninterested  or 
careless  physician  whose  diagnosis  is  hasty  or  ill- 
founded,  renders  it  as  hopeless  to  expect  good  social 
work  as  good  medical  results  for  his  cases.  Conditions 
outside  the  Dispensary  itself  may  render  social  service 
for  certain  cases  practically  a  vain  attempt.  A  city 
in  which  convalescent  facilities  were  almost  absent 
would  gravely  limit  the  effectiveness  of  social  work  for 
one  class  of  patients.  A  dominant  industry  in  which 
long  hours,  low  wages  and  poor  working  conditions 
were  prevalent  would  seriously  curtail  the  value  of 
social  service  in  dealing  with  another  large  class  of 

*A  wide-awake  Admission  Desk  in  the  charge  of  a  person  with  social 
training  helps  to  "spot"  patients  whose  social  needs  might  otherwise 
be  passed  over. 


114  DISPENSARIES 

patients.     The  remedy  would  have  to  be  sought  along 
other  lines  than  case-work. 

3.  The  Personnel  of  a  Social  Service  Department 

One  of  the  overshadowing  problems  in  medical 
social  service  is,  and  long  will  be,  the  securing  and 
training  of  workers.  The  question  often  asked,  oftener 
indeed  than  any  other,  is : — ' '  What  is  a  trained  social 
worker?"     ''Just  what  does  'training'  mean?" 

A  trained  social  worker  means  a  person  who  has 
learned  to  make  critical  hut  sympathetic  judgments  of 
the  human  problems  usually  presented,  and  who  has 
also  learned  how  these  can  be  dealt  with  effectively  in 
practice.  As  an  example  of  the  questions  which  face 
medical  and  social  workers  and  which  need  trained 
social  judgment  for  their  answer,  we  may  cite: 

Shall  material  relief  be  obtained  for  a  family  for  the  three 
or  four  months  during  which  the  father  will  be  in  an  in- 
stitution because  of  sickness,  or  shall  the  five  children  and 
mother  be  placed  in  four  different  homes  of  willing  relatives 
during  that  period;  a  course  to  which  the  mother  strenuously 
objects. 

Shall  a  delicate  child  with  kind-hearted  but  quarrelsome 
and  uneducated  parents,  be  placed  in  a  country  home  for 
six  months;  or  shall  an  attempt  be  made,  through  the 
parents'  love  for  the  child,  to  reconstitute  family  life  suffi- 
ciently to  enable  the  girl  to  get  well  at  home? 

Shall  an  unmarried  pregnant  girl  of  21  be  urged  to  marry 
the  father  of  her  child  if  the  man  is  willing  but  the  girl  has 
lost  her  confidence  in  him,  or  shall  she  be  helped  to  fight  her 
battle  of  life  alone? 


SOCIAL  SERVICE  115 

The  answers  to  such  questions  as  these  cannot  be 
made  merely  by  a  kind  heart.  Kind  hearts  in  social 
workers  are  of  just  the  same  value  as  honesty  in 
bookkeepers.  Honesty  is  essential,  but  does  not  teach 
a  clerk  how  to  keep  books.  A  kind  heart  must  be  un- 
der the  direction  of  a  cool  head,  a  trained  judgment. 
Trained  social  judgment  involves  not  only  the  ability 
to  draw  the  right  conclusion  from  the  facts  that  are 
available,  but  the  equally  important  power  of  eliciting 
from  the  individuals  and  family  concerned  all  the 
essential  facts  upon  which  correct  judgment  must  be 
based. 

Trained  analytic  judgment,  warmed  by  a  broad 
human  sympathy,  will  enable  a  conclusion  to  be 
reached  as  to  what  the  exact  social  problem  of  the 
patient  is.  Then  is  demanded  practical  skill  in  dealing 
with  the  patient  and  his  environment  and  in  utilizing 
the  resources  of  the  community,  in  order  to  attain 
actual  results.  In  social  work  as  in  medicine,  treat- 
ment follows  diagnosis.  As  examples  of  practical 
questions  which  a  medical  social  worker  may  face 
during  a  course  of  social  treatment,  there  may  be 
mentioned : 

By  what  procedures  or  by  what  agencies  can  a  vacation  be 
obtained  for  a  young  colored  working  girl,  whom  the  doctor 
says  ought  to  be  in  the  country  for  two  months? 

How  shall  we  get  a  job  for  a  man  with  a  damaged  heart 
and  so  give  him  a  definite  though  necessarily  limited  earning 
power? 

How  can  we  adjust  the  home  life  of  a  neurasthenic  woman 
until  she  can  get  physically  on  her  feet  again? 


116  DISPENSARIES 

The  development  of  social  judgment  and  of  knowl- 
edge of  the  technique  of  social  treatment  should  be 
based  upon  training  along  two  lines : 

(1)  Judgment  is  primarily  trained  by  the  critical 
study  of  concrete  cases  and  by  actual  experience  in 
dealing  with  them  under  supervision.  This  training 
must  be  fortified  by  the  broader  study  of  social  forces 
and  movements.  This  in  turn  should  be  founded  on  a 
good  general  education,  in  which  it  is  desirable  that 
economics,  psychology  and  biology  should  have  been 
included. 

(2)  Knowledge  of  social  technique  must  be  based 
on  a  study  of  existing  social  organizations,  the  prob- 
lems faced  and  the  methods  employed  by,  other  social 
workers  and  agencies. 

Frequently  the  question  is  raised: — should  social 
workers  in  hospitals  or  Dispensaries  be  nurses?  If 
the  preceding  analysis  of  the  requirements  of  social 
work  is  correct,  this  question  belongs  in  the  considera- 
tion of  secondary  qualifications.  A  nurse's  training  as 
such  does  not  supply  the  essential  elements  required. 
Nurses  have  been  successful  social  workers.  So  have 
school  teachers  and  college  graduates  without  medical 
or  nursing  training.  The  practice  of  many  large  Social 
Service  Departments  in  institutions  of  the  highest 
rank,  has  shown  that  social  workers  who  are  not 
nurses  can  be  successful  as  Staff  Workers  and  as  Head 
Workers. 

Undoubtedly  a  nurse's  training  supplies  a  certain 
familiarity  with  the  atmosphere  of  a  medical  institu- 
tion, with  the  subject-matter  dealt  with  therein,  and 


SOCIAL  SERVICE  117 

in  so  far  it  is  valuable  to  the  medical  social  worker. 
The  practical  question  is  whether  three  years  spent  in 
securing  a  nurse's  training  is  the  most  profitable  ex- 
penditure of  time  for  a  woman  who  wishes  to  take  up 
medical  social  service.  The  nursing  profession  is 
itself  undergoing  modification,  and  particularly  de- 
veloping in  the  public  health  field.  The  educational 
needs  of  the  public  health  nurse  resemble  at  many 
points  those  of  the  medical  social  worker,  although  the 
activities  of  the  one  will  be  more  and  more  confined  to 
district  service,  while  the  other  will  more  and  more 
work  along  specialized  lines  within  or  for  an  institution. 
In  the  process  of  modifying  the  curricula  of  nursing 
education,  which  is  now  going  on,  alterations  may  be 
produced  which  will  enable  courses  of  study  to  be 
prepared  in  which  the  institutional  nurse,  the  public 
health  nurse,  and  the  medical  social  worker,  may  all 
share;  some  parts  being  in  common  for  all,  some  differ- 
ent for  each.  This  is  a  matter  for  the  future.  The 
immediate  question  is  the  development  of  a  supply  of 
trained  medical  social  workers  which  shall  not  be 
far  short  of  the  demand,  as  has  been  the  case  in  recent 
years.  The  point  of  highest  importance  is  to  attract 
to  the  field  of  medical  social  service  people  of  personal- 
ity and  initiative. 

4.  How  Much  Social  Service  is  Needed  in  a  Dispensary? 

A  final  question  of  great  importance  is,  how  large  a 
Social  Service  Department  does  a  Dispensary  of  a 
certain  size  require?  Since  conditions  and  needs  of 
patients  will  vary  widely  in  Dispensaries  even  within 


118  DISPENSARIES 

the  same  community,  no  general  answer  is  possible  to 
this  question.  With  a  Dispensary  deaUng  with  certain 
kinds  of  diseases,  or  with  certain  economic  or  social 
groups,  social  service  will  be  required  more  than  if  the 
clientele  is  of  a  different  sort.  The  question  can,  how- 
ever, be  answered  definitely  for  any  particular  institu- 
tion. A  study  or  survey  of  the  patients  of  a  particular 
clinic,  of  a  group  of  clinics  or  of  the  whole  institution, 
is  the  method  by  which  an  answer  can  be  found.  A 
series  of  five  hundred  or  more  patients  in  a  whole 
Dispensary  or  of  one  hundred  to  five  hundred  pa- 
tients in  a  particular  clinic,  may  be  studied  sufficiently 
to  enable  their  social  needs  to  be  classified.  It  has 
been  found  in  several  charitable  Dispensaries,  treating 
a  wide  range  of  diseases,  that — 

From  twenty  per  cent  to  thirty  per  cent  of  all  the  patients 
will  need  intensive  social  case-work  in  order  to  achieve  suc- 
cessful medical  results; 

From  forty  per  cent  to  fifty  per  cent  in  addition  ought 
to  receive  some  attention  from  the  Social  Service  De- 
partment, of  a  less  intensive  character,  and 

From  twenty  per  cent  to  thirty  per  cent  would  not  need 
the  attention  of  social  service  at  all. 

The  number  of  social  workers  necessary  to  deal 
properly  with  a  given  number  of  cases  is  a  question 
which  must  be  answered  by  experiment.  When  the 
type  of  case  is  known,  a  medical  social  worker  of 
experience  can  give  some  definite  advice  as  to  the 
number  which  can  usually  be  handled  by  a  worker 
within  a  given  period,  although  considerable  limits  of 
variation  must  be  admitted.     A  neurasthenic  patient, 


SOCIAL  SERVICE  119 

or  one  of  the  difficult  family  problems  sometimes  in- 
volved in  a  case  of  syphilis,  might  require  fivefold 
the  time  that  would  be  demanded  by  the  task  of 
helping  a  woman  secure  an  operation  or  a  man  to  get 
a  job  suited  to  his  physical  handicaps.  One  social 
worker  in  a  Department,  therefore,  might  be  able  to 
carry  during  the  course  of  a  year  200  different  cases, 
while  another  worker  no  more  competent  might  carry 
400  or  500  during  the  same  period. 

Summary 

1.  Knowledge  of  the  social  needs  of  the  patients  in 
the  Dispensary  or  in  the  particular  clinics,  is  the  foun- 
dation upon  which  the  character  and  organization  of 
a  Social  Service  Department  should  be  planned.  This 
knowledge  must  be  secured  by  clinic  studies  or  sur- 
veys, or  by  similar  study  of  the  patients  of  the  Dis- 
pensary as  a  whole. 

2.  The  medical-social  worker  is  to  be  held  respon- 
sible first  of  all  for  social  diagnosis  and  for  securing  the 
facts  on  which  this  must  be  based. 

3.  The  policy  in  carrying  out  social  treatment  should 
be  to  utilize  as  fully  as  possible  all  outside  agencies  of 
relief,  education,  childcaring,  public  health  and  civic 
welfare. 

4.  The  assignment  of  workers  to  different  clinics  or 
to  different  phases  of  the  work  within  the  Dispensary 
must  be  made  according  to  the  following  principles : 

a.  Personal  contact  between  the  worker  and  numbers  of 
patients  promotes  initiative  and  complete  handling  of  needs 


120  DISPENSARIES 

and  is  furthered  by  the  assignment  of  workers  directly  to 
cUnics. 

b.  The  speciaHzation  of  each  worker  along  the  lines  of  a 
particular  medical  problem  or  closely  related  group  of  medi- 
cal problems  promotes  efficiency. 

c.  Oversight  or  neglect  of  cases  which  do  not  fall  within 
the  field  of  any  specialized  worker  must  be  avoided  by  period- 
ical clinic  surveys,  by  the  co-operation  of  the  admission 
desk,  and  retaining  some  workers  in  sufficiently  unspecial- 
ized  fields  to  devote  their  time  flexibly  to  any  case  of  need. 

d.  Care  should  be  taken  to  minimize  the  burden  of  execu- 
tive or  clerical  duties  upon  social  workers  assigned  to 
chnics.  Otherwise  the  amount  of  social  work  they  can  do 
will  be  unduly  Hmited. 

5.  The  Head  of  the  Social  Service  Department 
should  be  responsible  to  the  Superintendent  of  the 
Hospital  or  Dispensary  and  be  held  fully  responsible 
for  all  details  of  policy  and  of  organization  within  her 
department,  as  well  as  for  case-work. 


BUILDINGS  121 


CHAPTER   IX 
DISPENSARY  BUILDINGS 

Much  has  been  written  on  institutional  construc- 
tion, but  little  with  reference  to  the  right  arrangement 
and  spacing  of  the  different  rooms,  sections  and  divi- 
sions which  house  the  living  elements  of  a  Dispensary. 

I.  General  Planning  of  a  Large  Dispensary 

The  plan  of  even  a  new  building  for  a  Dispensary 
must  often  be  determined  largely  by  other  considera- 
tions than  the  needs  of  the  Dispensary  itself.  The 
general  layout  of  the  hospital  may  require  a  certain 
wing  to  be  used  for  the  out-patient  department,  or  the 
particular  plot  of  land  available  for  a  Dispensary  may 
determine  in  advance  limits  within  which  the  architect 
must  work.  One  fundamental  point  should  always  be 
held  in  mind :  A  Dispensary  essentially  requires  adapta- 
tion to  large  numbers  of  people,  each  of  whom  is  in  the 
building  only  a  comparatively  short  time,  but  many  of 
whom  are  in  the  building  at  certain  times  all  together. 
Consequently  ample  air  space  is  essential  and  plenty 
of  light. 

As  a  corollary  the  square  type  of  building  more  than 
two  stories  high  is  to  be  avoided,  unless  planned  so  the 
central  portion  can  be  lighted  adequately  by  daylight. 
When  a  building  of  two  stories  can  have  a  central 
court,  with  a  large  ventilating  skylight,  a  building  of 


122 


DISPENSARIES 


the  square  type,  as  shown  in  a  later  plan,  may  be  very 
acceptable.  When  a  building  for  a  large  Dispensary 
must  stand  on  a  restricted  plot  of  ground,  and  be 
three  or  four  stories  in  height,  thirty-six  to  forty  feet 
should  be  the  maximum  width.     The  ''L"  or  '^U'' 

PLAN  A 


5tcoND  Flooil  Plan 


5cAtt.lMM  ■  w  ■  ■  m 


ground  plan  will  work  out  excellently  when  feasible. 
Very  commonly,  in  planning  a  hospital  with  a  number 
of  large  units  standing  out  from  a  certain  side  of  a 
corridor  or  administration  building,  one  of  the  units 


BUILDINGS 


123 


will  be  assigned  to  the  out-patient  department.  This 
will  therefore  be  from  thirty-six  to  forty  feet  in  width, 
two  to  five  stories  high,  and  in  length  may  have  to 
conform  to  the  rest  of  the  hospital  plan  instead  of  to 
the  exact  space  requirements  of  the  Dispensary  itself. 
Plans  A,  B  and  C  will  illustrate  some  of  these  points. 

PLAN  A 


f  12.57-  PtOO^-pLAN 


5cAi.t  gpom  m.m.mit. 


i^Feer 


In  the  basement  would  be  lockers  and  lavatories  for  employees,  and 
space  for  clinic  records.  The  cabinets  holding  the  active  records  and 
the  alphabetical  index  make  most  of  the  walls  of  the  partition  sur- 
rounding the  Cashier  and  the  Admitting  Officer.  If  the  Institution  is 
independent  of  a  hospital,  the  basement  must  also  provide  for  a  phar- 
macy store-room,  general  store-room,  heating  plant  and  laundry. 


124 


DISPENSARIES 
PLAN  B 


Connecting  Co'^hwov^ 


Medical    and    Suex^ical  Clinaic 


6cAUEtn.»BWBMr 


A  typical  unit  of  a  large  hospital  group  utilized  for  a  Dispensary. 
One  floor  only  is  shown  to  illustrate  arrangement.  Admitting  hall  and 
administrative  ofl&ces  would  be  on  floor  below  (ground  floor);  other 
clinics  on  floors  above  and  in  basement. 


BUILDINGS 


125 


In  locating  an  out-patient  building  with  reference  to 
the  other  buildings  of  the  hospital  (when  an  entire 
hospital  plant  is  designed  as  a  w^hole),  it  is  to  be  borne 
in  mind  that  the  Dispensary  may  receive  more  pa- 


126  DISPENSARIES 

tients  than  all  the  other  parts  of  the  hospital  put 
together.  Hence  its  entrance  should  be  as  accessible 
as  possible  from  the  main  streets,  and  yet  not  be  so 
placed  as  to  interfere  with  the  ambulances,  automo- 
biles, patients  coming  to  the  wards,  or  visitors  to  the 
wards  or  private  rooms.  It  is  highly  important  that 
the  laboratories  of  the  hospital  and  the  X-ray  depart- 
ment shall  be  as  accessible  as  possible  to  the  Dispen- 
sary, so  that  examinations  of  either  kind  can  be  made 
with  the  least  possible  transference  of  patients. 

On  the  whole,  if  the  Dispensary  is  located  in  one 
wing  of  a  group  of  hospital  buildings,  it  is  most  desir- 
able to  have  this  wing  close  to  the  main  administrative 
portion  of  the  hospital.  Large  numbers  of  patients 
are  referred  to  and  from  the  Dispensary  and  the 
wards,  and  for  this  and  other  reasons,  it  is  helpful  if 
the  Dispensary  be  near  the  administrative  offices. 
The  record  system  of  a  large  Dispensary,  requiring  the 
handling  of  hundreds  of  clinic  records  in  a  day,  should 
be  correlated  administratively  as  well  as  medically 
with  the  hospital  records,  and  the  record  rooms  for  the 
hospital  and  Dispensary  are  best  managed  if  close 
together. 

During  recent  years,  many  out-patient  depart- 
ments have  been  started  more  or  less  experimentally, 
and  have  to  occupy  rooms  which  were  formerly  as- 
signed to  other  purposes.  They  must  fit  themselves 
in  as  best  they  can.  The  foregoing  suggestions  are 
written  primarily  for  new  buildings,  but  their  applica- 
tions will  be  apparent  to  situations  where  existing 
quarters  must  be  utilized  for  out-patient  purposes. 


BUILDINGS  127 

Too  frequently  out-patient  departments  have  been 
planned  by  sections.  Each  medical,  surgical,  or 
special  department  has  received  the  consideration  of 
the  chiefs  of  its  own  staff.  The  staff  sketch  out  the 
number  of  rooms  and  the  arrangement  they  would 
like.  The  architect  and  building  committee  have 
these  suggestions  laid  down  with  considerable  force  as 
necessary  parts  of  the  building.  Then  what  space  is 
left  over,  is  allotted  to  admitting  and  administration. 
As  a  consequence,  a  number  of  existing  Dispensaries, 
which  show  excellent  arrangements  in  certain  details 
of  clinics,  present  inadequate  provision  for  the  ad- 
ministrative work.  Ample  administrative  space  is  one 
of  the  first  requirements  of  a  Dispensary,  particularly 
if  it  is  likely  to  grow  as  most  Dispensaries  do.  It  is 
comparatively  easy  to  add  on  rooms  for  additional 
clinics,  or  even  to  put  certain  clinics  in  an  adjoining 
room  or  building,  but  if  an  admission  hall,  record 
room,  or  other  administrative  services  are  cramped, 
there  will  be  an  increasing  burden  upon  the  institution 
as  it  grows,  and  a  burden  which  is  often  difficult  to 
remedy. 

In  the  administrative  space  we  should  provide  for, — 

1.  A  vestibule,  or  covered  court,  where  baby  carriages 
can  be  left  in  safety  from  the  weather,  and  j'-et  not  in  the 
way  in  the  admitting  hall  itself.  A  vestibule  also  saves  con- 
siderable tracking  of  dirt  in  the  admission  hall. 

2.  Ample  waiting  space,  and  space  for  the  chief  lines  of 
passage  in  the  main  admitting  hall.  Waiting  space  must 
be  for  new  patients  in  the  first  instance,  who  must  wait  their 
turn  for  examination  at  the  admission  desk,  and  they  must 


128  DISPENSARIES 

be  provided  with  seats  sufficient  for  the  maximum  number 
who  are  Ukely  to  be  in  at  any  one  time.  In  a  cUnic  period 
lasting  two  hours,  between  fifty  and  eighty  per  cent  of  the 
total  number  of  new  patients  admitted  are  likely  to  be 
seated  at  admission  benches  at  any  one  time. 

Waiting  space  for  old  patients  may  be  mostly  standing 
space,  as  brought  out  in  the  chapter  on  admissions.  Sim- 
ilarly for  pharmacy  patients,  if  the  sj^stem  of  distributing 
medicines  is  properly  expedited.  But  for  both  a  certain 
amount  of  seating  space  must  be  provided;  about  a  tenth  of 
the  maximum  number  served. 

3.  Space  for  admissions,  as  brought  out  in  Chapter  XII — 
the  admission  desk,  the  cashier's  desk,  etc.,  with  the  Unes 
of  traffic  properly  planned  so  as  to  avoid  cross-currents. 

4.  Record  room  space.  Room  enough  to  store  all  the 
clinical  records,  alphabetical  and  diagnostic  indexes,  etc., 
without  taking  any  more  floor  space  than  is  necessary,  and 
yet  without  crowding — as  either  error  wastes  time.  Space 
for  growth  and  space  outside  the  admission  hall,  for  storage 
of  the  records  that  are  only  rarely  consulted,  are  highly 
important. 

5.  Space  for  executive  offices,  including  social  service.  A 
large  Dispensary  needs  a  private  office  for  the  superintendent 
of  the  out-patient  department;  a  suitable  room  for  the 
medical  staff;  a  staff  lavatory;  cloak  and  rest  rooms  for 
the  nurses,  social  workers  and  other  employees;  social 
service  offices;  a  stenographer's  office;  and  supply  rooms  (if 
the  Dispensary  is  separate  from  the  hospital  and  cannot  use 
the  general  hospital  supply  rooms  for  its  stock  of  material). 
The  Staff  Room  need  not  be  close  to  the  admitting  hall,  nor 
need  the  cloak,  rest  or  supply  rooms;  but  the  executive 
offices  of  the  superintendent  and  of  social  service  should  be 
adjoining   or  near  to  the   main  admitting   hall.    Broom 


BUILDINGS  129 

closets  with  slop  sinks  are  important.  A  room  must  be 
provided  in  the  Dispensary,  or  close  by  it  in  the  hospital, 
where  the  cash  received  for  fees  may  be  taken,  counted  and 
checked  in  privacy  and  safety.  The  stenographic  service 
must  be  located  so  as  to  be  accessible  to  those  most  needing 
it. 

2.  Some  Details  of  Construction 

From  the  nature  of  its  work,  a  dispensary  building 
must  contain  at  one  time,  a  large  number  of  people, 
but  people  who  are  up  and  about.  Nevertheless,  if 
the  building  is  more  than  a  story  high,  fireproof  con- 
struction is  desirable.  Where  a  Dispensary  is  the 
out-patient  department  of  a  hospital,  its  general  style 
and  construction  will  follow  the  hospital  architecture. 
The  types  of  plumbing,  doors,  and  partitions  found  in 
standard  hospital  work,  for  sanitary  and  for  technical 
reasons,  are  generally  to  be  preferred  in  a  Dispensary. 
Rounded  corners  and  other  devices  which  promote 
easy  cleaning  and  diminish  accumulation  of  dust 
(radiators  which  do  not  touch  the  floor,  for  example) 
should  be  installed.  A  Dispensary  sometimes  is  at 
work  only  in  the  daytime,  and  needs  little  artificial 
lighting  except  for  purposes  of  special  examination 
and  operations.  When,  however,  as  is  the  case  in  a 
number  of  institutions,  late  afternoon  or  evening 
clinics  are  held,  good  artificial  lighting  in  the  waiting- 
room,  corridors,  and  elsewhere  is  necessary.  The 
indirect  or  semi-indirect  system  is  to  be  preferred.  In 
examining  rooms,  lighting  must  be  adapted  to  the 
special  requirements  of  the  physician  or  surgeon,  but 
with  any  direct  illumination  much  care  should  be  taken 


130  DISPENSARIES 

in  locating  the  fixtures,  so  as  to  avoid  lights  which 
will  shine  directly  into  the  eyes  of  patient,  physician, 
nurse,  or  other  workers,  when  they  are  in  their  usual 
positions  in  the  room. 

Floors  in  a  Dispensary  also  need  to  be  planned  for 
the  special  requirements  of  different  parts  of  the 
building.  In  the  admitting  hall  and  main  corridors 
they  must  stand  a  great  deal  of  traffic,  far  more  than 
the  wards  or  corridors  of  a  hospital.  A  wooden  floor, 
well-laid,  is  durable  but  not  sanitary,  and  an  impervi- 
ous concrete  or  tile  should  be  utilized.  For  operating 
rooms  and  other  rooms  in  surgical  clinics,  where 
liquids,  blood,  pus,  etc.,  may  be  spilled  on  the  floor, 
a  similar  impervious  flooring  is  essential.  In  examin- 
ing rooms  in  medical  clinics,  in  history  rooms,  offices, 
and  in  waiting-rooms  of  particular  clinics,  where  there 
is  only  a  moderate  amount  of  traffic,  linoleum  is  easier 
for  the  feet,  amply  durable,  and  more  attractive  than 
any  of  the  hard,  impervious  floorings. 

The  finish  of  walls  and  woodwork  should  receive 
attention.  Washable  paint  is  desirable.  Since  pa- 
tients, particularly  children,  in  passing  along  corridors 
and  in  rooms  put  their  hands  upon  the  walls  and  wood- 
work, it  is  well  to  have  a  comparatively  dark  tone  to  a 
height  of  approximately  four  and  a  half  feet.  Above 
that  the  color  should  be  as  light  as  possible.  Best  of 
all  is  vitrified  tile,  up  to  five  feet,  but  the  expense 
often  negatives  this.  It  must  be  remembered  that 
whereas  in  the  hospital  wards,  the  patients  must  lie 
in  bed  looking  at  the  walls,  in  the  Dispensary  no  one 
patient  is  in  the  same  place  for  a  long  period.     It  is 


BUILDINGS  131 

important  that  the  place  be  bright,  airy  and  look 
clean  as  well  as  be  clean.  Light  wall  tones,  preferably- 
white,  are  the  best,  but  white  requires  much  more  care 
than  even  cream,  and  still  more  than  a  light  buff. 
It  is  desirable,  in  order  that  the  educational  opportuni- 
ties afforded  by  the  waiting-room  be  utilized,  that 
places  on  the  walls  be  provided  so  that  charts,  health 
posters,  etc.,  may  be  displayed.  Cork  or  linoleum 
surfaces,  flush  with  the  walls,  are  the  best,  for  then 
charts  of  varying  size  can  be  put  up  with  thumb 
tacks,  or  suspended  from  hooks. 

Rooms  that  are  to  be  used  for  medical  teaching, 
talks  to  nurses,  social  workers,  mothers,  and  other 
groups  of  patients,  may  well  be  provided  with  black- 
boards, which  again  should  be  flush  with  the  wall. 
Benches  for  patients  to  sit  upon,  or  chairs,  are  likely 
to  mar  even  hard  plaster  walls  severely,  when  placed 
with  their  backs  near  the  wall,  as  they  often  must  be. 
This  can  be  largely  obviated  by  rubber  pads  attached 
to  the  backs  of  the  furniture  at  the  proper  points,  or  by 
projections  attached  to  the  legs,  so  as  to  strike  the  wall 
base  and  hold  the  back  of  the  seat  away  from  the 
wall. 

Keeping  a  Dispensary  clean  is  no  light  matter. 
Even  if  mats  and  scrapers  are  placed  near  the  en- 
trance doors,  considerable  quantities  of  dirt  are 
necessarily  brought  in  on  the  feet  of  those  who  enter 
the  admission  hall.  The  main  corridors  show  the 
effect  most,  but  the  floors  of  every  hall,  corridor  and 
room,  used  during  the  clinic  period,  need  to  be  cleaned 
after  the  clinic  is  over.     Vacuum  cleaners  are  practi- 


132  DISPENSARIES 

cally  useless  for  mucli  of  this.  In  the  clinics  where 
surgical  work  of  any  kind  is  done,  liquids  on  the  floor 
and  moist  waste  need  to  be  wiped  or  taken  up  before 
the  floor  is  scrubbed. 

The  general  toilet  facilities  of  the  building  need  to  be 
carefully  planned.  As  brought  out  in  Chapters  X  and 
XI,  certain  clinics  must  have  toilet  facilities  of  their 
own  for  special  reasons.  The  medical  staff,  the 
officers  and  employees,  must  have  toilet  provisions 
separate  from  those  used  by  patients.  The  general 
men's  toilet  should  have  urinals  as  well  as  seats.  All 
toilet  seats  had  best  be  of  the  open  front  type. 

One  or  more  drinking  fountains  should  be  provided. 
There  ought  to  be  one  in  the  main  admission  hall  and 
at  least  one  additional  on  each  floor.  The  best  type 
is  that  in  which  several  streams  of  water  come  spouting 
from  the  inner  side  of  a  circle,  converging  to  form  a 
central  uprising  stream,  so  that  it  is  impossible  for  the 
lips  to  touch  any  metal.  It  is  best  when  practicable 
that  the  water  be  kept  running  continuously  in  the 
fountain  while  the  clinics  are  active.  Care  should  be 
taken  to  provide  steps  so  that  children  as  well  as 
adults  can  conveniently  use  the  fountains.  In  the 
absence  of  fountains,  individual  paper  cups  should  be 
supplied  to  clinics  so  that  patients  can  secure  drinking 
water  on  request. 

In  a  building  of  more  than  two  stori  ?  and  basement, 
an  elevator  is  almost  essential,  and  it  is  highly  desir- 
able even  in  a  low  building.  It  should  not  be  ex- 
pected that  all  patients  will  use  the  elevator,  but  those 
who  have  cardiac  disease,  who  are  lame,  or  feeble,  or 


BUILDINGS  133 

who  have  a  baby  to  carry,  should  have  the  privilege. 
Elevator  passes  may  be  issued  if  necessary. 

Ventilation  is  always  a  problem  when  large  num- 
bers of  people  are  gathered  together.  The  merits  and 
defects  of  artificial  ventilation,  and  the  various  systems 
thereof,  have  been  fully  treated  by  others,  and  need 
no  special  discussion  here.  In  a  Dispensary,  it  is 
possible  to  get  good  ventilation  ^' naturally,'^  by  open- 
ing windows;  but  this  requires  careful  planning  of 
seating  space,  window  boards  to  break  drafts,  tran- 
soms running  up  to  the  ceiling  to  take  out  top  air,  and 
above  all,  constant  supervision  to  make  sure  that  the 
windows  are  intelligently  opened,  closed,  and  ad- 
justed to  the  outside  temperature  and  winds.  In 
practice  this  is  a  difficult  task.  The  desideratum  is, 
to  have  provision  for  natural  and  for  an  exhaust  sys- 
tem of  artificial  ventilation. 

3.  Arrangement  of  Clinics 

Certain  general  principles  of  the  arrangement  of 
rooms  for  use  as  clinics  may  be  outlined  at  this  point. 
Division  may  be  made  into  two  heads.  Medical  and 
Surgical. 

A.  Medical.  A  typical  medical  unit  for  a  clinic 
includes  (1)  a  waiting  corridor;  (2)  a  history  cor- 
ridor, or  admitting  room;  (3)  an  examining  room. 

In  Plan  A,  showing  a  two-story  Dispensary,  of  the 
central  hall  type,  the  arrangement  of  rooms  in  a 
Medical  Clinic  is  indicated,  on  the  second  floor  of  the 
building.     The  waiting  corridor  is  that  around  the 


134  DISPENSARIES 

central  hall.  The  patient  then  passes,  called  by  the 
clerk  or  other  person,  into  the  inner  or  history  corridor, 
where  the  clinical  clerk,  nurse,  social  worker,  or  physi- 
cian himself,  takes  the  medical  and  social  history. 
The  inner  rooms  are  the  examining  rooms,  into  which 
patients  are  sent  for  undressing  and  physical  examina- 
tion. The  history  corridor  has  the  advantage  of 
greatly  increasing  the  privacy  of  the  examining  room. 
It  also  serves  as  a  useful  means  by  which  a  single  clerk 
or  clinic  manager  can  attend  to  the  executive  details 
of  even  a  large  clinic,  calling  the  patients  from  the 
waiting  corridor  in  suitable  order,  distributing  the 
patients  to  those  who  take  the  histories,  then  sending 
them  to  the  examining  rooms  as  these  are  ready. 

In  some  types  of  buildings  it  is  difficult  to  secure  a 
history  corridor  without  making  a  dark,  unventilated 
space,  between  the  outer  room  and  waiting  hall  or 
corridor.  In  some  cases  this  difficulty  can  be  partly 
overcome  by  separating  the  history  corridor  from  the 
waiting  corridor  merely  by  part  partitions,  seven  feet 
high.  In  some  types  of  building,  however,  and  often 
where  rooms  originally  intended  for  other  purposes 
must  be  adapted  to  the  use  of  a  Dispensary,  it  will  be 
necessary  to  utilize  a  single  room  as  an  admitting 
room  for  an  entire  clinic,  in  place  of  a  corridor  running 
across  the  doors  of  all  the  examining  rooms.  If  an 
admitting  room  can  be  surrounded  by  examining 
rooms,  a  very  convenient  plan  is  found,  but  in  many 
cases  the  examining  rooms  must  be  set  out  in  a  row 
next  to  the  history  room  and  the  patient  after  the  his- 
tory has  been  taken  must  pass  back  into  the  waiting 


BUILDINGS  135 

corridor  in  order  to  reach  the  more  distant  examining 
rooms.  As  a  consequence  there  is  less  expedition  in 
management,  somewhat  less  privacy,  and  more  bur- 
dens upon  the  clinic  manager  and  the  physician,  than 
if  a  history  corridor  can  be  used. 

Part  partitions,  seven  feet  high,  are  suitable  in  many 
instances  for  examining  rooms.  In  a  clinic  for  adults 
(particularly  for  women),  there  should  be  at  least  one 
fully  enclosed  room  where  conversation  between  doctor 
and  patient  can  be  carried  on  in  full  privacy.  In  a 
children's  clinic  the  need  for  this  is  diminished.  It  is 
not  desirable,  however,  to  have  more  than  two  ex- 
amining booths,  separated  by  part  partitions,  within  a 
single  room.  Otherwise  the  noise  carried  from  one 
booth  to  another  is  likely  to  be  troublesome. 

B.  Surgical.  While  the  arrangements  in  a  Medical, 
Pediatric,  or  Neurological  Clinic,  may  be  in  the  main 
similar,  the  requirements  on  the  Surgical  side  must 
vary  widely  on  account  of  the  highly  specialized  nature 
of  certain  branches  of  surgery,  and  the  technical 
equipment  demanded.  These  details  are  entered  into 
in  the  next  two  chapters.  In  a  general  Surgical  Clinic 
the  arrangements  may  be  not  dissimilar  to  those  de- 
scribed for  the  Medical,  so  far  as  the  waiting  corridor, 
history  corridor  and  examining  rooms  are  concerned, 
but  there  must  be  operating  rooms  in  addition. 
Furthermore,  a  considerable  part  of  the  routine  work 
in  most  Surgical  Clinics  consists  of  dressings,  and 
treatment  of  wounds  or  superficial  lesions.  Brief 
histories  are  taken  and  the  examining,  treatment  and 
history  rooms  can  be  one.     It  is  most  desirable,  how- 

10 


136  DISPENSARIES 

ever,  to  have  a  history  corridor  with  the  operating 
room  opening  from  it,  a  large  dressing  room  also,  and 
one  or  two  small  examining  rooms.  In  a  Surgical 
Clinic  of  small  size,  the  operating  room  and  acces- 
sories can  be  so  located  as  to  serve  for  both  male  and 
female  sections. 

Plan  B  shows  an  arrangement  for  a  section  of  a 
large  Dispensary  of  the  corridor  type.  Often  the 
necessity  of  adapting  quarters  previously  occupied  for 
hospital  purposes,  will  tax  the  ingenuity  of  a  dispensary 
manager.  A  room,  about  twenty  to  thirty  feet  in 
size,  formerly  used  as  a  ward,  may  have  to  be  em- 
ployed for  clinical  purposes,  despite  a  highly  incon- 
venient arrangement  of  doors  and  windows.  When 
he  cannot  do  the  best  he  knows,  the  dispensary  super- 
intendent must  do  the  best  he  can. 

4.  The  Small  Dispensary 

The  number  of  hospitals  of  moderate  size,  in  small 
communities,  which  have  undertaken  out-patient 
work  in  recent  years,  indicates  the  desirability  of  plans 
for  small  out-patient  departments.  Where,  for  ex- 
ample, only  ten  or  a  dozen  rooms  are  available,  the 
situation  must  be  quite  different  from  what  which 
faces  the  architect  of  a  large  Dispensary.  The  fol- 
lowing list  of  rooms  suggests  what  might  be  done  in 
quarters  in  which  twelve  rooms  and  a  vestibule  are 
available. 

Vestibule 
1.  Admission  Hall 

Waiting  space  with  benches 


BUILDINGS  137 

Admitting  booth 

Record  booth  (might  be  a  small  separate  room  ad- 
joining the  main  room) 

Administration  and  Social  Service  room  or  booth 
(these  may  be  partitioned  off  with  seven  foot 
partitions  from  the  main  room,  or  merely  with 
screens) 

2.  Pharmacy:  one  room 

3.  Medical   Chnic  (two   rooms:  preferably  one   large 

4.  room  and  a  second  room  divided  into  two  rooms 
or  two  booths  by  a  part  partition) 

5.  Surgical  CHnic  (three  rooms:  (1)  History,  examin- 

6.  ing  and  dressing  room;  (2)  operating  room;  (3) 

7.  small  examining  room) 

8,  9.  Children's  CHnic  (same  as  the  Medical) 

10.  Eye,  Ear,  Nose  and  Throat  CHnic  (two  rooms;  the 

11.  operating  work  under  ether  can  be  performed  in 
the  Surgical  operating  room  if  necessary) 

12.  Dental  CHnic  (one  room) 

As  indicated  in  a  preceding  chapter,  the  above  list 
of  clinics  are  those  most  needed.  Where  the  space 
does  not  admit  of  all  of  these  being  in  operation  at  one 
time,  climes  must  double  up. 

Another  and  important  type  of  Dispensary  is  the 
Health  Center,  described  in  Chapter  XVIII.  While  this 
largely  emphasizes  preventive  work,  it  is  likely  to  in- 
clude, and  more  and  more  in  the  future  will  include, 
a  Tuberculosis  Clinic  for  diagnosis  and  treatment,  a 
Children's  Clinic,  and  examining  if  not  treatment 
services  for  adults.  The  treatment  clinics  wiU  usually 
be  held  at  other  hours  than  the  simply  preventive 
work,  and  the  same  rooms  can  be  used  over  again. 


138 


DISPENSARIES 


< 


BUILDINGS  139 

Plan  D  indicates  an  arrangement  for  a  Health  Center, 
which  will  be  more  intelligible  on  comparison  with  the 
description  on  pages  315  et  seq.  Frequently  Health 
Centers  must  be  established  in  existing  buildings,  as, 
for  example,  in  a  dwelling  house.  The  arrangement 
suggested  is  adaptable  to  such  conditions. 

5.  Location  of  Dispensaries 

People  may  be  brought  to  a  hospital,  but  they  must 
come  to  a  Dispensary.  Accessibility  to  the  population 
needing  its  services  is  an  important  consideration  in 
fixing  a  Dispensary^s  location.  The  experience  of 
such  notable  institutions  as  the  new  Dispensary  of 
Washington  University,  St.  Louis,  or  of  the  Dispensary 
of  the  Medical  School  of  the  University  of  California 
in  San  Francisco,  is  good  evidence  that  an  important 
Dispensary  will  draw  a  clientele  from  every  part  of  a 
large  city  and  its  environs.  A  teaching  Dispensary  in 
particular,  or  any  other  Dispensary  having  on  its  staff 
many  of  the  best  known  physicians  of  the  community, 
is  in  considerable  measure  independent  of  location 
within  the  limits  of  a  city.  Proximity  of  the  teaching 
Dispensary  to  the  medical  school  is  convenient  but 
not  necessary. 

It  goes  without  saying,  however,  that  a  Dispensary 
situated  on  the  outskirts  is  neither  as  convenient  nor 
as  useful  as  if  more  centrally  placed.  An  out-patient 
department  of  a  hospital  need  not  be  an  adjacent 
building,  although  there  are  some  administrative 
advantages  and  economies  if  it  is.  But  a  hospital 
situated  on  the  edge  of  a  city,  or  in  a  well-to-do  resi- 


140  DISPENSARIES 

dence  section,  might  well  have  its  out-patient  depart- 
ment at  a  distance  in  an  industrial  section.  The  com- 
munity would  usually  receive  thus  better  medical 
service  than  if  the  out-patient  department  were  con- 
ducted at  the  hospital  site  in  an  inconvenient  location 
for  thousands  of  people,  or  on  the  other  hand  if  it 
were  working  in  the  center  of  the  city  as  a  Dispensary 
not  connected  with  a  hospital  at  all. 

The  more  a  Dispensary  enters  into  preventive  work, 
the  more  it  needs  to  be  near  the  people  whom  it 
serves.  The  serious  and  difficult  cases  will  go  or  be 
sent  for  miles  to  see  the  '' professor  doctor"  or  the 
specialist.  The  minor  illnesses,  and  those  considered 
by  the  patient  as  only  slight — even  when  really  serious 
— need  a  Dispensary  nearby.  The  Health  Center 
above  all  must  be  brought  close  to  the  people,  into  the 
very  midst  of  its  neighborhood. 

So,  in  locating  a  Dispensary,  the  managing  authori- 
ties must  consider  the  size,  layout  and  social  groupings 
of  the'r  community;  and  the  situation  of  existing 
hospitals  and  Dispensaries  or  of  the  hospital  with 
which  the  Dispensary  is  to  be  connected.  They  must 
weigh  the  relative  advantages  of  accessibility  and 
quiet ;  of  a  pleasant  site  versus  a  location  amid  tene- 
ment houses  and  factories.  Considerations  of  the 
cost  of  land  in  different  parts  of  a  city  of  course  enter 
in.  The  final  decision  must  be  based  above  all  upon 
a  clear  conception  of  the  exact  scope  and  character  of 
the  work  which  the  particular  Dispensary  ought  to 
do,  and  of  the  relations  of  this  work  to  the  people  who 
need  it. 


CLINICS  141 


CHAPTER  X 

DISPENSARY    CLINICS:    EQUIPMENT;   ORGANIZA- 
TION;   EDUCATION   AND    PREVENTIVE 
MEDICINE 

Bearing  in  mind  the  necessity  of  adapting  details  to 
institutions  of  varying  size,  a  brief  account  may  be 
given  of  each  of  the  usual  clinics  into  which  a  Dispen- 
sary may  be  divided.  In  addition  to  outlines  of 
equipment  and  management  under  the  title  of  each 
clinic,  certain  general  relations  to  the  Staff,  to  medical 
students  and  to  patients,  are  discussed  under  topical 
headings.  The  Laboratory,  Pharmacy  and  certain 
other  divisions  of  a  Dispensary  which  are  not  strictly 
climes,  must  also  receive  attention. 

General  Medical  Clinic 

In  considerable  measure,  this  clinic  is  a  diagnostic 
center  and  clearing-house  for  adult  patients,  as  the 
Children's  Medical  Clinic  is  for  children.  The  exam- 
ining rooms  must  be  well  lighted  and  as  quiet  as  pos- 
sible, and  equipped  with  examining  tables.  The 
point  is  often  raised  whether  it  is  better  to  have  certain 
routine  tests  done  within  the  clinic,  rather  than  in  the 
central  Laboratory  of  the  Dispensary.  In  many 
clinics  it  is  a  routine  (and  a  desirable  one)  to  have  a 
qualitative  test  for  sugar  and  albumen  made  of  the 
urine  of  every  new  patient,  and  of  old  patients  from 


142  DISPENSARIES 

time  to  time  when  indicated.  The  simplicity  of  these 
tests  and  of  certain  others  which  are  frequently  made, 
render  it  often  desirable  for  a  large  Medical  Clinic 
to  have  a  room  devoted  to  laboratory  work,  with  a 
technician,  an  interne,  a  medical  student,  or  a  member 
of  the  Staff,  to  perform  the  tests. 

There  must  of  course  be  a  stethoscope  for  each  phy- 
sician. Blood-pressure  apparatus  is  necessary,  as 
many  as  one  for  every  ten  new  patients  on  the  average 
clinic  day  being  desirable.  Equipment  for  stomach 
lavage  and  other  gastroenterological  work  should  be 
available,  and  if  there  is  much  of  this,  a  special  room  is 
a  convenience.  A  cardiograph,  because  of  its  expense, 
will  for  sometime  be  available  to  only  a  few  institutions. 

In  a  small  Medical  Clinic,  men  and  women  patients 
may  be  called  in  the  order  of  their  arrival,  as  in  a  pri- 
vate office;  but  in  a  large  clinic,  it  will  be  much  more 
convenient  to  separate  the  two  sexes,  so  that  one  set 
of  physicians  see  the  men,  and  another  set  see  the 
women  patients.  New  patients  may  pass  through 
somewhat  the  following  routine: — Weight  recorded 
on  the  record  card;  pulse,  temperature  by  mouth  and 
blood-pressure*  also  recorded;  a  specimen  of  urine 
secured  for  examination;  a  history  taken  by  the  phy- 
sician who  is  to  make  the  examination,  or  by  a  student 
under  his  direction.  The  patient  then  should  be  sent 
to  the  examining  room,  and  instructed  to  undress 
sufficiently  for  the  examination.  In  the  management 
of  a  large  clinic,  a  nurse  (a  pupil  nurse  or  trained  attend- 

*  Blood-pressure  will  usually  be  taken  by  the  physician  himself,  in 
the  examining  room. 


CLINICS  143 

ant  is  acceptable)  may  well  take  the  weight,  pulse 
and  temperature,  secure  the  specimens  of  urine  from 
the  women  patients,  and  see  that  they  get  to  the  ex- 
amining room  and  are  encouraged  or  assisted  to  pre- 
pare themselves  for  examination.  In  a  large  clinic 
theses  duties  may  be  divided  between  the  nurse  or 
attendant  and  a  clinic  secretary  or  assistant. 

The  number  of  patients  which  should  be  seen  by  a 
medical  staff  of  given  size  will  depend  considerably 
upon  the  organization  of  the  clinic  and  the  paid, 
trained  assistants  available.  Where  the  physician 
has  to  do  all  the  work,  except  securing  name,  age, 
address  and  other  data  about  the  patient  (which  are 
taken  at  the  Admission  Desk)  he  should  allow  not  less 
than  twenty  minutes  to  the  average  new  case,  and 
preferably  thirty  minutes.  Where  data  concerning 
temperature,  weight,  urine,  etc.,  are  secured  and  re- 
corded by  other  persons,  and  a  preliminary  history  is 
taken,  before  the  patient  is  sent  to  the  examining  room, 
the  physician  need  not  go  to  the  patient  until  he  is 
ready  for  examination,  and  the  actual  average  time 
spent  by  a  physician  on  a  new  case  may  be  reduced  to 
between  fifteen  and  twenty  minutes,  without  lower- 
ing of  standards.  Old  patients  will  usually  require 
from  six  to  twelve  minutes  of  time,  depending  on  the 
conditions  already  indicated.  The  following  staff 
would  be  desirable  for  administering  properly  a  Gen- 
eral Medical  Clinic,  extending  over  two  hours,  and 
receiving  an  average  of  fifty  patients,  of  whom  about 
half  would  be  men  and  half  women,  and  of  whom  about 
one-quarter  would  be  new  patients : — 


144  DISPENSARIES 

A  Physician-in-Chief ; 

Four  Assistant  Physicians; 

A  Nurse,  Pupil  Nurse,  or  Trained  Attendant; 

Two  Social  Workers; 

A  Clinical  Clerk  or  Executive,  who  calls  in  the  patients 
in  suitable  order  from  the  waiting-room;  sees  that  the 
records  get  to  the  doctors  when  needed;  and  admin- 
isters the  follow-up  system; 

An  additional  Woman  Attendant  or  Volunteer  on  the 
women's  side  would  be  desirable. 

The  part  which  may  be  played  by  medical  students 
in  such  a  clinic,  is  touched  upon  in  a  later  section 
of  the  next  chapter. 

One  of  the  neglected  phases  of  clinical  work,  partic- 
ularly in  general  medicine,  has  been  the  food  problems 
of  patients.  These  have  been  generally  ignored  unless 
the  case  presented  some  special  medical  problem  of 
nutrition  as  in  diabetes  or  disturbances  of  the  gastro- 
intestinal tract.  Yet  probably  a  large  majority  of 
the  families  of  dispensary  patients  are,  through  lack 
of  knowledge  of  food  values  and  of  ''home  economics,'^ 
getting  food  poorly  adapted  to  their  needs  and  more 
costly  than  it  needs  to  be.  The  Food  Campaign  of 
this  War-time  is  awakening  us  all  to  this,  and  we  may 
hope  to  see  advisors  and  workers  in  dietetics  in  close 
contact  with  dispensary  clinics  in  future.  The  study 
of  a  patient's  general  condition  and  environment 
should  not  be  considered  complete  unless  an  approxi- 
mate food  schedule  and  budget  for  a  week  has  been 
obtained.  The  physician  is  moreover  prone  to  lay 
down  requirements  of  diet  for  patients  without  suffi- 


CLINICS  145 

cient  consideration  of  the  economic  aspect.  Food 
such  as  suits  well-to-do  private  patients  is  suggested 
when  much  less  expensive  but  satisfactory  substitutes 
could  be  proposed.  The  dietitian  will  be  of  service  in 
the  pediatric  as  well  as  in  the  general  medical  clinic, 
and  elsewhere  in  the  Dispensary,  and  will  be  an  inval- 
uable adjunct  to  the  Social  Service  Department  and 
to  the  physicians  themselves  (cf.  page  147). 

Out  of  a  General  Medical  Clinic  often  bud  certain 
useful  and  important  sub-divisions.  That  for  Tuber- 
culosis is  referred  to  hereafter  (page  183).  Pro- 
vision for  making  periodical  physical  examinations 
("Health  Surveys")  of  individuals,  should  be  made, 
and  this  form  of  preventive  work  should  be  encour- 
aged. At  some  Dispensaries,  Gastroenterology  has 
been  made  a  special  branch  or  sub-clinic  within  the 
General  Medical.  So,  with  much  advantage,  have 
Cardiac  Diseases.  Occupational  Diseases  have  also 
been  made  into  a  special  section  in  a  few  institutions. 
It  is  essential  to  have  a  physician  especially  trained 
in  the  industrial  relations  of  disease,  and  in  the 
diagnosis  and  treatment  of  the  chief  occupational 
diseases  of  the  community.  Skilled  social  service 
and  in  some  cases  assistance  from  visiting  nurses 
are  essential  with  most  cardiac  and  occupational  cases. 

Children's  Medical  or  Pediatric  Clinic 

The  general  arrangement  and  routine  of  a  Pediatric 
Clinic  follow  in  many  respects  those  of  the  Adult 
Medical.  Separation  of  the  sexes  for  children  under 
fourteen  years  of  age  is  not  necessary  in  the  waiting- 


146  DISPENSARIES 

rooms,  but  individual  examining  rooms  or  booths  are 
required  as  for  adults.  Each  child  is  usually  accom- 
panied by  its  mother,  or  some  older  person,  and  often 
other  children  in  the  family  are  ^'brought  along,"  so 
that  a  Children's  Clinic  presents  a  problem  of  dealing 
with  many  persons  besides  the  patients  themselves. 
It  is  generally  convenient  in  a  large  clinic,  that  some 
room  or  rooms  be  set  aside  for  babies,  if  possible  also 
a  separate  waiting-room;  and  a  particular  nurse,  or 
pupil  nurse,  assigned  to  the  sole  task  of  weighing  the 
babies  and  seeing  that  they  are  ready  for  examination. 

It  is  of  great  importance  that  the  Children's  Clinic 
use  every  possible  means  to  prevent  the  spread  of  con- 
tagious disease.  One  room  should  be  provided  in  the 
clinic  where  suspicious  or  actual  cases  of  contagious 
disease,  which  slip  through  the  first  line  of  defense  at 
the  admission  desk,  can  be  immediately  isolated.  A 
member  of  the  staff,  or  preferably  a  paid  assistant, 
should  be  given  the  definite  responsibility  of  seeing 
that  this  isolation  is  carried  out  and  maintained  until 
proper  provision  is  made  for  the  patient. 

The  equipment  of  a  Pediatric  Clinic  will  include 
the  examining  tables  in  the  examining  rooms,  scales 
for  weighing  infants,  another  for  older  children. 
Blood-pressure  and  urine  examinations  are  not  usually 
made  as  routine  in  a  Children's  Clinic,  but  facilities 
for  performing  them,  when  indicated,  should  be  avail- 
able. There  is  usually  no  need  of  a  departmental 
laboratory.  A  large  Children's  Clinic  needs  its  own 
toilet. 

The  clinical  management,  and  the  number  of  pa- 


CLINICS  147 

tients  in  proportion  to  the  size  of  the  staff,  may  follow 
closely  that  of  the  Adult  Medical  Clinic,  the  difference 
being  chiefly  due  to  the  fact  that  the  sexes  are  not 
separated;  that  certain  of  the  tests  made  upon  adults 
are  unnecessary  as  routine;  while  on  the  other  hand 
the  special  problems  of  dealing  with  young  children, 
and  of  explaining  situations  to  their  mothers,  are 
unique  features  of  the  Pediatric  Clinic.  For  a  clinic 
of  an  average  of  fifty  children  daily,  a  staff  of  not  less 
than  four  physicians,  preferably  five,  one  of  whom  is 
Physician-in-Chief,  should  be  available,  for  the  usual 
clinic  period  of  two  hours.  There  should  be  a  nurse, 
who,  if  there  are  many  babies,  will  be  assigned  entirely 
to  them,  otherwise  be  devoted  to  the  clinic  as  a  whole ; 
two  social  workers,  and  at  least  one  clinical  clerk. 
Another  assistant,  who  may  be  a  volunteer,  will  be 
very  helpful  in  the  waiting-rooms  and  corridors. 

In  the  Medical  and  the  Pediatric  Clinics,  the  duties 
of  the  social  workers  will  be  guided  by  the  considera- 
tions discussed  in  Chapters  VII  and  VIII.  The  exact 
adjustment  of  the  executive,  clerical  and  social  service 
duties  among  the  physicians  of  the  staff,  the  nurses, 
the  social  workers,  and  the  clerical  force,  should  be 
worked  out  in  each  case,  according  to  the  following 
principles:  (1)  have  clerical  work  done  by  a  paid  per- 
son; (2)  concentrate  all  responsibility  for  the  executive 
management  of  the  clinic  in  the  hands  of  one  person; 
(3)  have  the  medical  chief  of  the  clinic  largely  free 
from  routine,  for  deciding  assignment  of  cases,  acting 
as  consultant,  and  determining  medical  policy.* 

*  Special  divisions  of  a  pediatric  clinic  for  undernourished  children 
("Nutrition  Clinics")  and  for  cardiac  cases,  have  been  successfully- 
worked  out  and  are  to  be  encouraged. 


148  DISPENSARIES 

Neurological  Clinic 

While  from  one  standpoint,  neurology  is  a  highly 
developed  specialty,  from  another  standpoint  the 
work  of  a  Neurological  Clinic  is  that  of  a  General 
Medical  Clinic,  plus  an  additional  special  point  of 
view.  In  a  general  Dispensary,  a  considerable  pro- 
portion of  the  neurological  cases  will  have  been  re- 
ferred from  other  clinics,  and  already  have  a  record  of 
^^ history"  and  treatment  for  various  diseases  or 
symptoms.  Yet  even  so,  not  less  than  a  half  hour 
should  be  allowed  on  the  average  for  each  new  patient. 
The  data  which  should  be  gathered  in  the  Neurologi- 
cal Clinic  concerning  the  patient  are  those  required  in  a 
Medical  Clinic,  plus  such  additional  information  as 
is  to  be  secured  by  the  physician  himself  in  conference 
with  the  patient  and  by  his  physical  examination. 
Eye  conditions  are  so  often  of  importance,  that  it  is  a 
question  whether  a  Neurological  Clinic  should  not  be 
equipped  with  apparatus  for  the  examination  of  the 
eyes,  instead  of  referring  patients  to  the  Eye  Clinic. 
Decision  on  this  point  must  be  based  on  considera- 
tions of  practical  convenience,  rather  than  on  prin- 
ciples; such  as  the  inclination  of  the  neurologist  and 
the  oculist  themselves,  the  location  of  the  two  depart- 
ments concerned,  the  executive  staff  available  for 
securing  prompt  transfer  of  the  patient  and  report  back. 

Similarly,  the  frequency  of  syphilis  of  the  central 
nervous  system  relates  the  Neurological  Department 
closely  to  the  main  department  treating  syphilis. 
This  will  be  discussed  a  little  later. 

The  equipment  of  the  Neurological  Clinic,  besides 


CLINICS  149 

the  requisites  for  general  examination,  as  in  a  Medical 
Clinic,  should  include  outfits  for  testing  the  special 
senses,  so  far  as  this  is  not  done  by  means  of  reference 
to  other  special  clinics.  Wall  charts  of  the  body  and 
the  nervous  system  are  particularly  useful  in  this 
clinic.  Outfits  for  examination  of  the  reflexes,  includ- 
ing a  hammer  for  testing  the  knee-jerk,  and  a  dyna- 
mometer, are  important .  Even  a  very  small  neurological 
clinic  needs  a  clerk  or  executive;  a  large  one  needs  a 
nurse  (or  trained  attendant)  also.  Social  Service  is  a 
very  frequent  need  in  neurological  cases  and  no  neu- 
rological clinic  can  secure  satisfactory  results  unless  a 
social  worker  is  either  attached  to  the  clinic  or  acces- 
sible from  the  general  office  of  the  Social  Service 
Department. 

How  far  shall  psychiatric  work  be  carried  on  in  con- 
nection with  neurology?  Many  cases  referred  to  the 
neurologist,  particularly  children,  will  involve  the 
question  of  mental  defect,  and  this  can  only  be  de- 
termined by  psychological  as  well  as  medical  methods. 
Equipment  for  Binet-Simon  and  similar  tests,  while 
not  particularly  expensive,  requires  highly  specialized 
service,  usually  paid  service,  and  takes  considerable 
time.  Where  a  special  psychiatric  clinic  in  connec- 
tion with  a  hospital  for  the  insane  or  for  mental  dis- 
ease is  available  in  the  vicinity,  it  may  be  more 
desirable  not  to  carry  on  these  tests  in  connection  with 
a  Neurological  Department,  but  refer  them  to  the 
other  clinic,  even  if  outside  the  institution.  In  many 
Dispensaries,  however,  no  such  outside  expert  facili- 
ties will  be  available.     The  mental  hygiene  movement 


150  DISPENSARIES 

is  likely  to  create  an  increasing  number  of  psychiatric 
clinics,  and  these  clinics  will  be  more  efficient  when 
they  can  be  made  part  of  a  general  Dispensary,  than 
if  maintained  independently  of  the  general  and  special 
clinics  which  will  be  of  mutual  assistance. 

General  Surgical  Clinic 

In  all  but  small  surgical  clinics,  there  must  be 
separate  room  for  sexes  for  dressing  and  minor  surgical 
procedures.  If  the  Surgical  Clinic  is  only  of  moderate 
size,  a  single  operating  room,  for  operations  under 
local  or  general  anesthesia,  may  be  used  for  both  men 
and  women,  but  in  large  clinics  two  operating  rooms 
should  be  provided,  although  a  single  sterilizing  equip- 
ment will  suffice.  It  is  desirable,  even  in  very  small 
clinics,  to  have  infected  cases  dressed  in  separate 
rooms  from  clean  cases.  The  treatment  of  fractures 
in  out-patient  clinics  presents  special  problems.  If 
more  than  a  small  amount  of  such  work  is  required,  a 
special  room  for  fractures  is  desirable.  At  least  one 
small  room  is  essential.  In  regard  to  operations, 
general  anesthesia  should  be  permitted  only  (1)  after 
the  surgeon  in  charge  has  personally  passed  on  the 
case,  and  (2)  when  a  suitable  recovery  room  is  pro- 
vided, with  a  nurse  in  attendance  until  the  patient  is 
ready  to  go  home.  Operations  under  general  anes- 
thesia should  in  general  not  be  permitted  in  an  out- 
patient clinic  unless,  in  addition  to  the  recovery  room, 
facilities  are  available  in  the  same  institution  or  in  the 
vicinity,  whereby  the  patient  can  be  put  into  a  hospital 
bed  promptly  when  his  condition  requires. 


CLINICS  151 

The  large  amount  of  radiographic  work  in  connec- 
tion with  a  Surgical  Clinic  renders  it  convenient  if  the 
X-ray  Department  is  located  nearby,  but  this  is  by 
no  means  essential.  The  examination  of  pathological 
tissue  specimens,  etc.,  from  the  Surgical  Clinic,  will 
of  course  be  performed  in  the  central  laboratory  of 
the  Dispensary. 

Much  of  the  detailed  organization  of  the  Surgical 
Department  will  depend  upon  the  extent  to  which 
specialties  are  built  up  within  the  department,  or  are 
separated  into  special  clinics.  Thus  Orthopedic, 
Genito-Urinary  surgery,  Proctology,  or  Gynaecology, 
may  be  run  as  separate  clinics,  or  as  divisions  of  the 
Surgical  Department.  The  extent  to  which  the  proc- 
ess of  sub-division  is  carried  will  depend  upon  the 
general  considerations  of  medical  organization  treated 
in  Chapter  VII.  It  is  quite  practical  to  have  a  mem- 
ber of  the  Surgical  Department,  who  becomes  espe- 
cially interested  in  rectal  diseases,  for  example,  or  in 
genito-urinary  surgery,  have  such  cases  referred  to 
him  for  a  definite  period  and  be  assigned  a  particular 
room,  with  suitable  equipment,  for  carrying  on  these 
cases.  There  may  be  rotation  in  service  among  mem- 
bers of  the  department  along  the  lines  of  various 
specialties,  thus  affording  different  men  the  opportu- 
nity to  broaden  their  knowledge.  Where  the  degree 
of  specialization  in  the  medical  practice  of  the  local 
community  does  not  justify  the  creation  of  a  special 
department  for  these  divisions  of  surgery,  this  plan 
will  be  of  particular  advantage. 

The  equipment  of  a  Surgical  Clinic,  including  oper- 
11 


162  DISPENSARIES 

ating  room,  sterilizers,  examining  tables,  dressing 
tables,  instruments,  cabinet,  etc.,  involves  a  multi- 
plicity of  details.  The  expense  for  a  clinic  treating  an 
average  of  fifty  patients  daily  might  range  between 
$1,000  and  $2,500,  depending  upon  the  elaborateness 
of  the  operative  procedures  on  the  patients,  and  the 
quality  of  the  apparatus  purchased.  Since  a  consid- 
erable proportion  of  the  patients  in  a  general  Surgical 
Clinic  come  with  minor  superficial  lesions,  for  the 
diagnosis  and  treatment  of  which  general  physical 
examination  is  not  necessary,  the  organization  and 
procedure  in  the  Surgical  Clinic  is  much  simpler  than 
in  the  Medical.  A  nurse  is  of  course  essential,  and  if 
the  clinic  is  large  there  must  be  one  for  the  male  and 
one  for  the  female  side.  In  some  instances  one  of  the 
two  nurses  will  give  much  of  her  time  to  the  operating 
room.  The  patient^s  history  is  generally  taken  by  the 
surgeon,  or  an  assistant,  while  the  patient  is  in  the 
dressing  room.  Cases  involving  a  general  physical 
examination  for  the  determination  of  diagnosis  will, 
as  soon  as  the  situation  is  clear,  be  sent  to  the  examin- 
ing table. 

There  must  be  careful  gradation  of  responsibilities 
among  the  members  of  the  Staff  of  a  large  Surgical 
Out-Patient  Department,  so  that  no  undue  responsi- 
bility for  advising  operations  or  determining  diagnoses 
shall  be  taken,  except  by  physicians  of  such  rank  as 
are  designated  by  the  Chief. 

Most  Dispensaries  do  not  assign  a  Social  Worker 
to  the  Surgical  Clinic  but  leave  the  surgeons  to  call 
one  in  when  necessary.     Correlation  of  the  work  of  a 


CLINICS  153 

Surgical  Clinic  with  a  Visiting  Nursing  service  is  often 
useful. 

Relationship  between  Patients  and  Physicians  in  Clinics 

The  establishment  of  a  personal  relation  of  confi-  f 
dence  between  the  patient  and  the  physician  is  no  less 
important  in  the  clinic  than  in  private  practice.     The 
great  enemy  of  this  relationship  is  hurry.     The  two 
essentials  are  time  and  continuity.     There  must  be  time  , 
enough,  above  all  at  the  first  interview,  for  the  physician  j 
to  make  a  thorough  examination,  and  to  explain  to 
the  patient  what  the  patient  ought  to  know  about  his  \ 
condition  and  its  treatment.     There  should  be  clinical 
organization  such  that,  on  returning  to  the  clinic,  the ; 
patient  shall  see  the  same  physician  again.     This  isj 
not  always  possible,  but  the  clinic  can  be  so  organized' 
that  in  the  main  it  shall  be  possible.  \ 

These  principles  apply  to  all  clinics,  but  with  some-  ^ 
what  less  force  to  the  Surgical  and  to  some  of  the 
specialties,  than  to  the  often  long-continued  health 
problems  faced  in  a  medical,  pediatric,  or  neurological 
department.  In  the  specialties  there  are  indeed  not 
infrequently  long-continued  and  difficult  medical 
problems  to  be  solved,  such  as  those  of  syphilis,  chronic 
troubles  of  the  eye,  or  ear,  defects  of  posture,  etc. 
Personal  relationship  and  continuity  of  touch  between 
physician  and  patient  is  of  vital  importance  in  such 
instances.  On  the  other  hand,  in  a  short  term  opera- 
tive case,  a  refraction  case,  a  cut  hand  or  burn,  con- 
tinuity of  touch  between  physician  and  patient  takes 
care  of  itself. 


154  DISPENSARIES 

In  the  organization  of  a  Medical,  Pediatric,  or  Neu- 
rological Clinic,  therefore,  the  Staff  should  be  so 
organized  that  the  Chief  either  (1)  sees  every  new  case 
and  assigns  it  to  an  assistant  for  continuous  treatment 
thereafter,  advising  him  concerning  the  diagnosis,  or 
else  (2)  holds  himself  ready  to  consult  with  each  assist- 
ant concerning  every  difficult  case,  and  expects  that 
such  consultation  will  be  asked  for.  Whichever 
procedure  has  been  followed,  each  assistant,  once  hav- 
ing taken  a  case,  will  see  the  same  patient  throughout 
the  period  of  treatment.  Where  staff  services  are 
split  up,  and  one  patient  must  pass  from  one  physician 
to  another,  as  at  the  end  of  a  six  months'  period,  there 
should  be  a  personal  consultation  between  the  physi- 
cians during  certain  overlapping  days  near  the  changes 
of  service,  during  which  the  old  patients  are  brought 
back  and  both  physicians  see  them  jointly. 

Continuous  relationship  between  a  physician  and  a 
patient  helps  toward  systematic  control  of  the  case. 
This  assists  in  diminishing  or  avoiding  a  disadvantage 
of  the  Dispensary,  viz.,  the  failure  of  various  special- 
ties to  co-ordinate  their  work.  The  patient  may  some- 
times be  said  to  fall  out  of  sight  amid  his  diseases! 
There  ought  to  be  one  controlling  clinic  for  each  case, 
the  physician  of  which  stands  in  the  relationship  of 
family  physician  to  the  patient.  Through  this  physi- 
cian the  opinions  and  procedures  of  all  the  specialists 
who  have  been  called  in  will  be  co-ordinated  and  inter- 
preted to  the  patient.  The  General  Medical  or  the 
Pediatric  Clinic  should  fulfill  this  co-ordinating  func- 
tion  in   many   instances.     To   realize   this   ideal   of 


CLINICS  155 

centralized  co-ordinated  medical  control  for  each 
case  is  not  easy;  but  it  is  the  ideal  to  strive  for. 
Needs  and  possibilities  in  this  direction  are  developed 
somewhat  in  Chapter  XXI. 

The  Dispensary  as  an  Educational  Institution 

Physicians  and  medical  students,  nurses  and  social 
workers,  trustees  and  patients,  must  come  to  the 
Dispensary  not  only  to  help  or  be  helped,  but  to 
learn.  The  Dispensary  should  bear  an  educational 
relation  to  each  of  these  groups,  and  in  large  measure 
this  education  can  be  organized,  so  as  to  be  a  standing 
element  in  the  institution's  work.  The  part  played 
by  the  Dispensary  in  medical  education,  graduate  and 
undergraduate,  has  increased  remarkably  as  medical 
education  has  become  less  didactic  and  more  practical. 
This  is  well  brought  out  in  the  notable  report  pub- 
lished by  a  Committee  of  the  Association  of  American 
Medical  Colleges  in  1916,  referring  to  the  teaching 
functions  of  a  Dispensary : — 

"After  all,  the  functions  of  a  Dispensary  are  essentially 
the  same  as  the  functions  of  a  hospital,  namely,  the  ade- 
quate care  of  the  patient,  the  instruction  of  medical  students 
and  the  advancement  of  medical  knowledge.  From  most 
points  of  view  the  same  conditions  hold  in  the  Dispensary 
as  hold  in  the  hospital.  Adequate  care  of  the  patient  must 
include  not  only  careful  examination  and  proper  treatment, 
but  also  instruction  in  methods  of  life  and  the  prophylaxis 
of  disease.  The  Dispensary  should  be  the  center  for  the 
dissemination  among  the  public  of  knowledge  of  preventive 
medicine.  In  the  Dispensary,  just  as  in  the  hospital,  the 
presence  of  the  medical  student  not  only  adds  to  the  effec- 


156  DISPENSARIES 

tive  working  force,  but  also  stimulates  the  attending  physi- 
cians to  a  better  type  of  work.  ...  A  properly 
equipped  and  adequately  maintained  Dispensary  is  one  of 
the  most  important  factors  in  clinical  instruction." 

When  medical  students  are  taught  in  large  classes, 
a  patient  presenting  a  disease  or  condition,  included 
within  the  subject  of  the  lecture,  is  brought  before  the 
class  for  demonstration.  Teaching  of  this  type  makes 
little  difference  to  the  conduct  of  a  clinic,  as  only  a  few 
picked  cases  are  used. 

The  more  effective  and  prevailing  method  is  to  have 
students  in  small  sections.  These  students  are  either 
(1)  in  groups  of  two  to  six  (more  than  four  is  not  very 
desirable).  They  are  brought  to  patients,  or  patients 
are  brought  to  them,  in  the  presence  of  the  instructor. 
Each  student  is  allowed  to  make  all  or  part  of  an  ex- 
amination himself,  and  then  the  case  is  discussed  by 
the  group  with  the  instructor.  (2)  According  to 
another  plan,  the  students  are  assigned  as  clinical 
assistants.  They  take  histories  of  patients,  they  make 
individual  examinations,  and  then  the  instructor  goes 
over  the  history  and  makes  his  own  examination. 
Such  student  assistants  obviously  do  some  of  the 
routine  work  of  the  clinic,  but  their  teacher  should 
give  them  time  for  instruction  which  will  fully  make 
up  for  whatever  time  they  save.  If  the  students  are 
used  in  such  a  way  as  to  expedite  the  clinic,  they  are 
not  likely  to  receive  the  best  instruction.  The  pres- 
ence of  students,  however,  is  a  great  stimulus  to  the 
clinic,  because  it  puts  the  members  of  the  Staff  on 
their  mettle.     The  Superintendent  of  the  Dispensary 


CLINICS  157 

ought  not  to  expect  that  the  presence  of  students 
will  enable  a  staff  to  do  more  work  in  the  same  time; 
but  it  should  enable  them  to  do  better  work. 

No  patient  should  be  used  for  demonstration  or 
examination  by  students,  except  with  his  consent,  or, 
in  the  case  of  children,  with  the  consent  of  a  parent  or 
older  person.  Certain  Dispensaries  affiliated  with 
medical  schools  refuse  treatment  when  patients  object 
to  being  examined  by  students.  Where  the  interests 
of  the  community  demands  that  a  certain  patient  re- 
ceive treatment,  a  Dispensary,  whether  associated 
with  a  medical  school  or  not,  must  think  very  carefully 
before  it  adopts  a  policy  against  treating  such  cases. 
As  a  matter  of  fact,  unwillingness  to  be  used  for  pur- 
poses of  medical  education  is  infrequent,  and  usually 
means  that  the  matter  has  not  been  properly  presented 
to  the  patient.  With  all  but  a  few  exceptional  indi- 
viduals, the  patient's  consent  can  be  readily  won  by  a 
frank,  but  tactful,  presentation  of  the  service  which 
the  patient  can  render  in  return  for  the  service  which 
is  furnished  him. 

The  value  of  histories  taken  by  students,  and  of  the 
records  made  by  them,  depends  largely  upon  the  de- 
gree of  critical  supervision  exercised  by  their  instructor. 
Where  students  are  held  up  to  a  high  standard,  the 
records  which  they  make  are  full  and  careful,  and, 
taken  together  with  the  corrections  and  additions  put 
down  by  the  teacher,  give  an  altogether  valuable 
presentation  of  the  case.  Upon  the  instructor  rests 
the  responsibility  for  achieving  this  result,  and  the 
pressure  of  the  executive  management  of  the  Dispen- 


158  DISPENSARIES 

sary,  as  well  as  of  the  Medical  School  with  which  the 
physician  is  affiliated,  should  begin  and  end  with  him. 

In  post-graduate  teaching  there  is  no  more  impor- 
tant field  than  the  Dispensary.  The  physician  al- 
ready in  practice  who  wishes  to  increase  his  knowl- 
edge of  diagnosis  or  treatment  in  general  medicine, 
or  to  perfect  himself  in  any  specialty  of  medicine  or 
surgery,  finds  in  the  Dispensary  an  opportunity  to 
deal  with  large  numbers  of  cases  along  the  lines  of  his 
particular  interest,  and  to  work  under  the  supervision 
of  a  man  from  whom  he  can  learn  at  every  contact. 
Thus,  the  graduate  schools  of  medicine  that  are  now 
arising  in  connection  with  various  medical  schools 
depend  largely  upon  out-patient  service,  as  do  those 
polyclinics  and  other  teaching  hospitals  which  seek 
especially  for  post-graduate  work.  The  graduate 
physician  is  of  course  given  a  freer  hand  in  a  clinic 
than  an  undergraduate  student.  A  group  of  graduate 
students  may  be  brought  together  for  conference  and 
informal  lectures,  but  in  the  main  the  teaching  of 
graduate  students  consists  in  letting  them  work  upon 
cases,  under  supervision  of  the  instructor;  in  other 
words  as  clinical  assistants. 

The  Dispensary  must  in  the  future  be  utilized 
largely  in  the  training  of  specialists,  for  a  considerable 
proportion  of  the  work  required  in  opthalmology, 
laryngology,  neurology,  dermatology,  syphilis,  gon- 
orrhea, pediatrics  and  chronic  diseases,  is  out-patient 
rather  than  bed  service.  Demand  is  growing  for 
some  definite  system  whereby  training  in  specialties 
shall  be  available  and  as  medical  education  perfects 


CLINICS  159 

itself  in  this  direction,  a  still  larger  utilization  of  the 
Dispensary  must  take  place. 

In  an  even  broader  way,  the  Dispensary  must  be 
one  of  the  chief  means  through  which  the  general 
body  of  the  medical  profession  shall  be  kept  abreast 
of  the  advances  in  medical  science  and  practice.  The 
Dispensaries  and  the  out-patient  departments  of 
hospitals  will  in  the  future  be  centers  of  periodical, 
practical  education  for  the  local  profession,  as  well  as 
of  the  more  definitely  organized  courses  under  the  aus- 
pices of  post-graduate  medical  schools.    (Of.  page  395 .) 

The  use  of  a  Dispensary  in  the  training  of  nurses 
is  yet  only  beginning.  Superintendents  of  training 
schools  have  often  failed  to  see  the  great  value  of  a 
Dispensary  in  this  connection.  Hospital  demands 
have  absorbed  so  much  attention,  that  both  the  needs 
and  the  usefulness  of  the  Dispensary  in  training  nurses 
have  been  often  obscured.  There  are  signs  that  this 
situation  is  changing.  In  a  Dispensary,  pupil  nurses 
meet  many  diseases  which  never  appear  in  hospital 
wards.  They  learn  many  treatment  procedures 
which  in  the  future  they  will  need  to  apply  whether  in 
private  practice,  in  institutional  work,  or  as  visiting 
nurses.  They  are  placed  in  a  much  more  flexible  and 
generalized  human  relationship  with  patients  and 
doctors  than  in  the  hospital,  and  have  a  larger  oppor- 
tunity for  display  of  personality,  initiative  and  execu- 
tive ability.  A  pupil  nurse  should,  during  the  latter 
part  of  her  training,  be  utilized  in  the  Dispensary  and 
pass  through  a  number  of  the  clinics,  not  necessarily 
through  all.     Modes  in  which  she  can  be  usefully  em- 


160  DISPENSARIES 

ployed  have  been  suggested  at  various  points  in  these 
chapters. 

The  training  of  workers  for  medical-social  service  is 
a  recent  development.  They  also  must  have  the 
experience  of  direct  contact  with  the  medical  and 
human  problems  of  patients.  Here  again  the  Dis- 
pensary provides  opportunities  without  which  no 
medical -social  worker  can  be  adequately  trained.  In 
the  best  courses  of  training  for  medical-social  work, 
the  Dispensaries  have  been  utilized  as  major  factors 
in  providing  students  with  practical  experience  under 
supervision.  Of  course  there  must  be  an  organized 
Social  Serrice  Department  to  whose  workers  the 
students  in  social  service  will  be  suitably  assigned. 

Volunteer  Workers  in  a  Dispensary 

The  Dispensary  offers  unusual  opportunities  for 
utilizing  not  only  the  good  will  of  volunteers  but  their 
personal  services.  What  a  volunteer  can  do  depends 
on  the  person,  for  there  are  exceptional  volunteers 
who  undertake  and  bear  large  daily  responsibilities. 
On  the  average  the  volunteer  worker  is  a  young  woman 
who  has  time,  energy,  a  strong  desire  to  help,  and  a 
willingness  to  give  from  one-quarter  to  one-half  of  her 
time.  Concrete  and  definite  tasks  must  be  offered 
them,  such  as : — 

Ushers  in  clinics  or  halls,  seeing  that  patients  know  where 
to  go,  that  they  come  to  the  doctors  in  turn,  that  they  get 
promptly  to  the  right  clinic  when  transferred; 

Clerical  work  with  records  in  cHnics,  writing  transfer  slips, 
follow-up  cards,  or  tabulating  statistics; 


CLINICS  161 

Clinic  managers  or  executives  (suitable  only  for  picked 
people) ; 

Taking  patients  to  hospitals,  charitable  organisations,  etc. 
(a  volunteer  with  her  automobile  is  often  a  friend  in  need) . 

Visiting  patients  in  their  homes  in  connection  with  the 
follow-up  system,  or  to  carry  a  message  or  a  bottle  of  medi- 
cine. 

It  is  essential  that  each  volunteer  be  responsible  to 
a  particular  person  for  direction  and  supervision.  At 
some  Dispensaries  a  chief  of  all  volunteers  is  ap- 
pointed, at  others  one  professional  worker  in  each 
clinic  directs  the  volunteers  in  her  department.  The 
wives,  daughters  or  friends  of  the  Trustees  often  form 
the  nucleus  of  a  body  of  volunteers,  and  the  number 
may  be  greatly  increased  by  the  personal  efforts  of  a 
few  interested  persons.  It  is  often  difficult  to  hold 
volunteers  during  the  summer  vacations,  but  some- 
times college  students  may  be  found  who  will  give  a 
month  of  their  vacation  to  practical  service.  It  is 
important  that  every  new  volunteer  be  instructed 
by  a  responsible  person  in  her  general  duty  toward 
the  Dispensary.  The  necessity  of  punctuality  and 
regularity  of  attendance  must  be  emphasized.  In- 
formation must  be  given  as  to  contagious  disease, 
prevalent  misconceptions  should  be  removed  and  yet 
caution  inculcated,  particularly  the  washing  of  hands 
before  eating,  when  leaving  the  Dispensary  or  any 
place  of  possible  exposure. 

Care  should  be  exercised  in  permitting  untrained 
volunteers  to  do  any  handling  of  patients,  particularly 
in  skin  or  surgical  clinics.    Volunteers   often  wish 


162  DISPENSARIES 

very  much  to  do  dressings,  but  only  those  who  have 
had  experience  and  who  can  be  trusted  to  work  on 
selected  cases  and  under  the  supervision  of  a  nurse, 
should  be  allowed  to  do  this  type  of  work. 

A  set  of  simple  rules  covering  the  preceding  and 
other  points  should  be  written  down,  given  to  each 
volunteer,  and  she  should  be  required  to  register  her 
name,  address,  and  time  promised  at  the  Dispensary, 
before  beginning  work.  Firm  but  tactful  insistence 
on  conformity  with  the  rules  does  not  drive  away  any 
worth-while  volunteer,  but  gains  her  respect  and  re- 
tains her  service.  Under  the  right  leadership  volun- 
teers develop  skill,  and  grow  in  devotion  and  enthu- 
siasm as  they  feel  themselves  advancing  in  power. 
A  group  of  effective  helpers  can  be  built  up  of  value  to 
the  Dispensary  and  a  leavening  influence  in  the  com- 
munity in  countless  ways. 

Preventive  Medicine  in  a  Dispensary 

Is  there  a  place  in  the  Dispensary  for  a  division 
which  has  not  usually  been  included,  namely  a  Depart- 
ment of  Preventive  Medicine  or  Hygiene?  Or, 
should  the  Dispensary's  endeavor  to  prevent  as  well 
as  to  cure  disease,  find  its  expression  in  each  clinic 
through  the  careful  individual  teaching  of  each  pa- 
tient, the  particular  thing  which  that  patient  needs  to 
learn  and  to  put  into  practice? 

Both  questions  ought  to  be  answered  in  the  affirma- 
tive. Every  clinic  must  do  the  bulk  of  the  preventive 
work  which  its  patients  require,  and  to  make  this 
effective  the  chief  requirements  are  sufficient  time  on 


CLINICS  163 

the  part  of  the  physicians  and  a  sufficient  staff  of 
nurses  and  social  workers  to  carry  out  the  various 
details  of  instruction,  by  word  of  mouth  in  the  clinic, 
or  by  demonstration  in  the  home.  The  existence  of  a 
Department  of  Preventive  Medicine  or  Hygiene  in  a 
Dispensary  might  conceivably  tend  to  render  other  de- 
partments less  interested  in  educational  and  preventive 
service  to  patients,  because  of  the  feeling  that  this 
was  the  responsibility  of  a  special  department.  But 
no  Department  of  Hygiene  can  teach  all  the  patients 
of  a  Dispensary.  Only  the  clinic  knows  the  individ- 
ual problems  of  its  patients.  There  is,  however,  a 
real  place  for  a  Department  of  Hygiene  and  we  may 
expect  to  see  such  develop  as  the  public  health  func- 
tions of  Dispensaries  are  brought  more  fully  into  view. 
A  Department  of  Hygiene  in  a  Dispensary  would 
have  the  responsibility  of  working  out  general  educa- 
tional functions,  part  of  which  would  be  undertaken 
by  itself,  and  part  by  the  several  clinics,  whose  staff 
would  be  stimulated  and  assisted  to  carry  out  those 
forms  of  instruction  which  must  be  adapted  to  the 
individual  case.  Such  a  Department  of  Hygiene 
would  have  to  be  under  the  direction  of  a  physician 
specially  trained  and  interested  in  this  type  of  work. 
Part  of  the  activity  of  such  a  Chief  would  be  research. 
His  main  field  would  be  less  the  acquirement  of  new 
knowledge  than  the  development  of  methods  by  which 
existing  knowledge  can  be  actually  applied  to  human 
service.  The  Dispensary  brings  large  numbers  of 
patients  together,  presenting  a  great  variety  of  medical 
and  conamunity  problems,  and  offers  an  almost  un- 


lU  DISPENSARIES 

developed  opportunity  for  teaching  the  lay,  as  well  as 
the  medical  community,  how  our  knowledge  concern- 
ing health  can  be  made  to  count  one  hundred  per  cent 
in  our  practical  application  of  it.  Some  of  the  obvious 
topics  for  such  studies  are  the  relation  between  housing 
conditions,  occupational  conditions  and  disease;  the 
character,  cost  and  method  of  use  of  patent  medi- 
cines in  self-treatment  of  various  ills;  the  work  of 
quacks  and  medical  correspondence  institutes;  the 
food  habits  and  dietaries  of  patients  of  various  sex, 
age,  vocational  and  national  groups;  the  daily  hy- 
giene and  habits  of  life  among  such  groups,  as  to  exer- 
cise, water-drinking,  defecation,  sleep.  Such  are  a  few 
of  the  subjects  on  which  we  need  more  knowledge  of 
the  facts,  derived  from  concrete  case  studies  such  as 
can  be  made  among  dispensary  patients.  Only  from 
such  knowledge  can  we  tell  how  and  where  to  apply 
educational  or  civic  effort  in  practically  effective  ways. 
The  second  field  for  a  Department  of  Hygiene  would 
be  in  the  study  of  methods  of  Health  Education,  and  the 
actual  educational  work  itself.  Just  what  is  the  rela- 
tive effectiveness  of  leaflets,  exhibits,  posters,  or  the 
spoken  word,  in  teaching  this  or  that  point  to  one  and 
another  type  of  individual?  How  shall  the  educa- 
tional efforts  of  a  Children's  Clinic  be  made  most 
effective  with  the  agencies  at  hand?  How  shall  we 
best  ensure  that  patients  do  not  leave  the  Pharmacy 
without  knowing  just  when  and  how  to  take  their 
medicines?  How  shall  we  best  induce  the  patients  of 
the  Dispensary,  and  also  persons  outside,  to  come  in 
for  periodical  Health  Examinations,  and  to  bring  their 


CLINICS  166 

children  for  the  same  purpose?  How,  in  general, 
shall  we  make  the  Dispensary  a  center  of  Health  Edu- 
cation as  well  as  of  Medical  Service?  Great  and  little 
foundations  for  medical  research  are  driving  pioneer 
paths  over  the  hills  of  knowledge.  Must  not  Depart- 
ments of  practical  Hygiene  follow,  in  public  health 
bureaus  and  in  Dispensaries,  which  shall  make  the 
roads  broad  and  safe  for  democracy,  so  that  democracy 
will  travel? 


166  DISPENSARIES 


CHAPTER   XI 

DISPENSARY  CLINICS,  CONTINUED:  SPECIALTIES 

AND  TREATMENT  CLINICS;  LABORATORY; 

X-RAY  DEPARTMENT;  PHARMACY 

The  Gynaecological  Clinic 

In  most  large  Dispensaries,  gynaecology  will  be 
separate  from  general  surgery.  The  department  may 
or  may  not  include  obstetrics.  In  a  Dispensary 
connected  with  a  medical  school  obstetrical  work  is 
usually  done  in  patient's  home,  by  graduate  physi- 
cians or  by  students  under  supervision,  and  also  in 
the  hospital  for  cases  needing  operative  or  other  special 
care  at  delivery.  In  such  Dispensaries,  the  obstetri- 
cal work  should  be  unified  with  gynaecology,  for  their 
mutual  advantage. 

The  Gynaecological  Clinic  should  therefore  provide 
not  only  for  the  diagnosis  and  treatment  of  the 
special  '^  diseases  of  women,"  but  also  examination 
to  determine  the  existence  of  pregnancy  when  ques- 
tioned, and  for  supervision  of  the  pregnant  woman  up 
to  the  time  of  confinement.  This  so-called  '^prenatal 
work"  is  of  increasing  importance,  and  every  gynaeco- 
logical clinic  should  either  conduct  it,  or  be  closely 
correlated  with  a  prenatal  clinic,  conducted  as  a 
public  health  clinic,  in  the  vicinity.  Visiting  nursing 
service  in  connection  with  such  prenatal  work  is 
essential  (see  pages  303-307) . 


CLINICS  167 

It  is  essential  to  have  privacy  for  the  individual 
examination,  and  a  woman  attendant  present.  A 
graduate  nurse  must  be  in  charge  to  insure  asepsis. 
Patients  should  be  seen  individually  by  the  physician. 
He  takes  the  history  and  questions  the  patient  care- 
fully about  the  various  problems  involved  in  her  case. 
The  patient  should  then  be  sent  to  the  examining 
room  or  to  a  separate  dressing  room.  After  the  nurse 
or  attendant  has  seen  that  the  patient  is  ready  upon 
the  examining  table,  the  physician  will  go  to  the 
examining  room. 

A  staff  for  a  Gynaecological  Clinic,  receiving  thirty 
patients  daily,  of  whom  about  five  would  be  new 
patients,  would  include  two  physicians,  one  graduate 
nurse,  one  social  worker  and  a  clerk.  The  addition  of 
a  trained  attendant  would  expedite  the  clinic,  as  a 
second  patient  could  be  in  preparation  for  examina- 
tion while  the  surgeon  is  examining  the  first. 

Should  gonorrhea  in  females  be  treated  in  a  Gynae- 
cological Department?  Frequently  it  is.  The  seque- 
lae and  complications  of  gonorrhea  closely  involve 
the  surgical  aspects  of  gynaecology.  It  is  practicable 
to  unify  gynaecology  with  general  surgery  in  the  Dis- 
pensary (under  the  system  of  specializing  members 
of  the  staff  referred  to  on  page  151)  and  to  treat  all 
gonorrhea  as  such  in  the  genito-urinary  clinic. 

The  equipment  of  a  Gynaecological  Clinic  should 
include  at  least  two  small  examining  rooms,  each 
provided  with  its  own  table,  and  preferably  with  its 
own  sterilizer  for  instruments  and  gloves.  Toilet 
facilities  should  be  very  accessible.     It  is   a  great 

12 


168  DISPENSARIES 

time-saver  to  have  at  least  one  more  examining  room 
than  there  are  physicians.  Facilities  for  cystoscopy 
are  essential,  and  a  pelvimeter  for  examining  pregnant 
women.  Unless  the  number  of  urine  tests  required  is 
very  large  they  should  be  sent  to  the  central  labora- 
tory. 

Genito-Urinary  Clinic 

The  scope  of  this  clinic  varies  considerably.  It  is 
often  difficult  to  draw  the  line  between  it  and  the 
General  Surgical.  In  some  institutions  the  Genito- 
Urinary  Clinic  is  for  men  only,  diseases  of  the  genito- 
urinary system  of  women  going  to  gynaecology.  In 
other  Dispensaries  the  Genito-Urinary  clinic  is  for 
both  sexes,  and  gynaecology  is  either  combined  with 
general  surgery  or  is  confined  to  a  restricted  field. 
Again,  the  Genito-Urinary  Department  sometimes 
includes  the  treatment  of  syphilis  and  gonorrhea,  as 
the  'Venereal  diseases,''  while  elsewhere  syphilis  is 
treated  in  connection  with  dermatology  or  in  a  de- 
partment by  itself. 

Decision  as  to  the  proper  scope  of  the  Genito-Uri- 
nary Clinic  in  any  particular  institution  will  depend 
upon  the  principles  laid  down  on  pages  84  and  151, 
and  partly  on  the  demands  made  by  local  public 
health  movements  for  dealing  with  gonorrhea  and 
syphilis. 

If  both  men  and  women  are  treated  in  the  Genito- 
Urinary  Clinic,  the  two  sections  must  be  kept  adminis- 
tratively separate  to  a  large  degree,  with  separate 
waiting-rooms.  If  syphilis  as  well  as  gonorrhea  is 
treated,  the  equipment  and  arrangement  specified  on 


CLINICS  169 

page  18  must  be  included,  and  at  least  one  additional 
room  will  be  required  for  men  and  one  for  women. 
Assuming  for  the  moment  that  only  gonorrhea  and 
the  surgical  aspects  of  genito-urinary  diseases  are 
included  within  the  scope  of  this  clinic,  the  following 
may  be  outlined : 

Gonorrhea  is  si  disease  which  requires  frequent 
visits  and  a  fairly  long  period  of  treatment,  and  there- 
fore the  proportion  of  visits  to  new  patients  will  be 
large.  Even  including  those  cases  which  are  trans- 
ferred to  other  institutions,  or  which  move  away  from 
the  city,  seek  treatment  elsewhere,  or  which  are 
*^lost,"  the  average  visits  per  patient  among  gonorrhea 
cases  should  be  between  fifteen  and  twenty,  and  any 
lower  figure  should  arouse  question  whether  proper 
supervision  and  control  of  the  disease  is  exercised. 
This  test  must  not  be  applied  to  a  Genito-Urinary 
Clinic  as  a  whole,  since  a  certain  proportion,  some- 
times a  large  proportion,  of  the  cases  in  the  clinic  are 
not  gonorrhea.  The  Chief  of  the  clinic  should  see  all 
new  cases.  In  a  large  clinic  the  patient  is  usually 
assigned  at  the  first  or  second  visit  to  an  assistant  for 
treatment,  if  this  is  of  a  routine  character;  but  the 
Chief  himself  or  a  designated  assistant  would  ordi- 
narily attend  to  a  case  where  the  cystoscope  was 
necessary.  It  is  desirable  that  the  Chief,  or  a  spe- 
cially designated  assistant,  should  see  the  patient  at 
each  revisit,  to  note  progress  and  indicate  further 
treatment.  The  same  physician  thus  sees  the  patient 
each  time,  even  though  a  different  physician  may  give 
the  local  injection,  etc.     The  presence  of  a  clerk  or 


170  DISPENSARIES 

trained  attendant  to  attend  to  records  and  details, 
care  for  instruments,  the  follow-up  system,  etc.,  is 
essential  unless  the  clinic  is  a  small  one. 

The  equipment  for  the  diagnosis  and  treatment  of 
gonorrhea  will  include  accessibility  to  a  laboratory 
for  examining  smears  and  urine  and  making  comple- 
ment-fixation tests.  Examining  and  treatment  tables, 
with  irrigators,  sounds,  catheters,  dilators,  bougies, 
etc.,  are  necessary.  The  cystoscope  is  essential, 
and  a  special  room  and  table  for  cystoscopy  are 
desirable,  though  not  necessary.  Some  Genito-Uri- 
nary  Clinics  do  a  good  deal  of  operating  under  local 
anesthesia  and  a  special  room  for  this,  with  operating 
and  instrument  tables,  etc.,  will  be  required.  Such  a 
room  may  also  serve  for  the  cystoscopic  work.  The 
sterilizing  equipment  must  be  carefully  looked  to. 
Much  the  most  convenient  arrangement  is  to  have 
the  treatment  room  cut  up  into  a  series  of  small  rooms, 
or  booths,  so  that  each  patient  has  a  room  or  compart- 
ment to  himself  during  treatment.  This  compart- 
ment should  preferably  contain  a  small  instrument 
sterilizer  so  that  each  physician  can  have  his  instru- 
ments, gloves,  etc.,  readily  accessible.  Much  time  is 
saved  by  such  an  arrangement  and  privacy  is  gained. 
A  utensil  sterilizer  for  the  basins,  etc.,  is  a  necessity 
in  the  clinic.  There  must  be  a  urinal  immediately 
accessible,  preferably  within  the  clinic.  A  clinic 
providing  for  three  physicians,  treating  men  only, 
should  have  a  trained  attendant  or  clerk  and,  if 
possible,  a  male  social  worker,  an  admission  or  his- 
tory room,  two  treatment  rooms  or  booths  with  the 


CLINICS  171 

urinal  accessible,  and  a  cystoscopy  room.  If  women 
are  also  to  be  treated  during  the  same  clinic  period, 
an  additional  history  room,  a  treatment  room  and  a 
nurse  will  be  required,  The  cost  of  the  examining 
tables,  sterilizing  equipment,  instruments,  clerical 
supplies,  follow-up  records,  etc.,  for  such  a  clinic, 
would  be  between  $800  and  $1,500. 

Orthopedic  Clinic 

This  specialty  has  advanced  in  a  remarkable  way 
from  a  narrow  and  slightly  considered  field  of  medical 
service  to  a  recognized  and  highly  important  branch 
of  remedial,  preventive  and  reconstructive  surgery. 
Its  widening  applications  to  the  control  and  promo- 
tion of  the  growth  of  children  had  been  established 
before  the  War,  while  the  War  itself  has  brought  to 
greater  prominence  than  ever  before  the  place  of 
orthopedics  in  the  rehabilitation  of  wounded  and 
crippled  soldiers,  as  well  as  to  men  and  women  in 
civilian  life  and  industry.  It  is  probable  that  a  large 
number  of  physicians  will  acquire  special  training  in 
orthopedics  as  a  result  of  War  activities.  It  is  much 
to  be  hoped  that  when  the  War  is  over  there  will  be 
a  sufficient  supply  of  such  specialists  to  enable  ortho- 
pedics to  be  a  separate  clinic  in  all  but  very  small 
Dispensaries,  instead  of  being  combined  with  general 
surgery. 

In  addition  to  the  usual  history  room,  and  examin- 
ing room,  the  Orthopedic  Clinic  requires  a  special 
room  for  plaster  work  and  apparatus  for  muscle  test- 
ing.    It  is  desirable  to  take  photographs,  to  record 


172  DISPENSARIES 

postural  defects,  and  to  have  a  frame  in  which  a  sub- 
ject can  be  placed  so  as  to  define  certain  fixed  points 
for  comparison  at  a  later  period  in  the  same  individual, 
when  photographed  thereafter.  It  is  a  question  how 
far  the  Orthopedic  Clinic  should  enter  into  treatment 
or  leave  these  to  special  Treatment  Departments,  such 
as  the  Zander  or  the  Massage.  Unless  the  Dispen- 
sary is  well  equipped  in  the  latter  respects,  the  Ortho- 
pedic Department  should  be  provided  with  bakers 
adapted  to  different|parts  of  the  body,  and  with  at 
least  simple  apparatus  for  corrective  gymnastics. 
The  clinic  must  have  a  nurse  or  trained  attendant  and 
a  considerable  portion  of  the  patients  will  usually  need 
social  work,  so  that  a  special  social  worker  is  desirable 
as  an  adjunct  to  any  large  Orthopedic  Clinic.  Cor- 
rective gymnastics  will  require  a  specially  trained 
person  at  those  periods  when  the  gymnastic  exercises 
are  to  be  conducted  for  individuals  or  small  classes. 

Apparatus,  such  as  braces,  plates,  belts,  special 
shoes,  corsets,  etc.,  are  required  by  many  orthopedic 
cases.  The  Dispensary  should  arrange  for  their 
provision  through  the  clinic  in  such  wise  as  shall 
ensure  the  patient's  procuring  what  is  needed,  and 
shall  enable  the  orthopedic  surgeon  to  see  that  the 
article  is  of  good  quality  and  properly  fitted.  This 
can  only  be  done  when  the  apparatus  is  brought  to 
the  clinic  before  it  is  given  to  the  patient.  Large 
Dispensaries  may  sometimes  have  their  own  shop  for 
making  surgical  and  orthopedic  appliances,  but  most 
institutions  will  make  arrangements  with  one  outside. 
Apparatus  will  usually  be  charged  for  at  prices  not  far 


CLINICS  173 

from  cost,  and,  as  indicated  on  page  274,  there  should 
be  arrangements  for  the  remission  of  fees,  or  for  pay- 
ment in  installments  when  necessary. 

Eye  Clinic 

In  many  middle-sized  communities  the  eye,  ear, 
nose,  and  throat,  are  treated  by  a  single  specialist, 
but  in  the  larger  places  the  oculist  is  a  specialist  by 
himself.  An  Ophthalmological  Clinic  is  important, 
both  as  an  aid  in  general  diagnosis  and  for  special 
service  to  those  with  defect  or  disease  of  the  eye. 
The  oculist  should  co-operate  particularly  with  the 
departments  of  General  Medicine,  Neurology,  Pedi- 
atrics, and  with  the  clinic  treating  syphilis.  Defects 
of  eyesight  found  among  children  as  a  result  of  medical 
inspection  in  the  public  schools  usually  constitute  a 
considerable  proportion  of  the  patients  in  an  Eye 
Clinic.  The  majority  of  these  are  refraction  cases. 
In  some  communities  eye  diseases  arising  out  of 
special  strains  or  hazards  connected  with  a  particular 
industry  raise  problems  of  medical,  industrial  and 
social  interest. 

The  work  of  an  Eye  Clinic  naturally  divides  itself 
into  two  divisions:  (1)  Refraction,  the  testing  of 
eyesight  and  fitting  of  glasses;  (2)  Pathological,  the 
diagnosis  and  treatment  of  eye  diseases.  In  a  small 
clinic  a  single  oculist  will  perform  the  whole  service; 
in  a  large  clinic  the  work  will  be  divided  among  many. 
The  tendency  is  for  the  Chief  to  take  the  major  part 
of  the  pathological  work  and  leave  the  refraction  work 
to  assistants.     This  division  of  labor  should  not  be 


174  DISPENSARIES 

carried  too  far,  as  it  gives  too  little  training  to  the 
assistants  in  the  diagnosis  and  treatment  of  diseases 
of  the  eye.  Refraction  work,  moreover,  not  infre- 
quently requires  highly  skilled  judgment  and  the 
Chief  should  be  prepared  to  do  his  share  of  it  and 
should  always  see  all  questionable  cases. 

Equipment:  (1)  the  usual  admitting  or  history 
room,  (2)  a  room  for  eye  testing.  This  must  be  at 
least  ten  feet  long,  in  which  case  a  mirror  must  be 
used;  or  preferably  twenty  feet  long,  so  that  the 
test  cards  can  be  seen  at  the  normal  distance  for 
which  they  are  planned.  (3)  There  must  be  a  ^^dark 
room''  for  the  examination  of  the  interior  of  the  eye. 
This  can  be  small,  but  should  be  ventilated  and  not  a 
mere  closet.  (4)  A  clinic  in  which  two  or  more 
oculists  are  engaged  should  have  a  fourth  room  for 
the  pathological  work.  There  must  be  an  ophthalmo- 
scope, ophthalmometer,  sets  of  lenses  for  eye  exami- 
nations and  for  fitting  glasses,  some  instruments  for 
minor  eye  surgery,  and  eye  testing  cards  (Snellen 
charts).  Instead  of  these  charts  the  patented  mechan- 
isms, which  show  only  one  line  of  the  different  size 
letters  at  one  time,  and  are  under  the  control  of  the 
oculist  twenty  feet  away,  are  a  great  convenience. 

The  provision  of  eye  glasses,  as  of  other  apparatus 
which  has  a  commercial  sale  outside,  needs  to  be  kept 
under  careful  control.  Unless  the  eye  work  of  the 
Dispensary  is  large  enough  to  justify  its  own  shop  for 
cutting  and  fitting  lenses,  an  arrangement  should  be 
made  with  a  local  optician  to  have  a  representative  in 
the  clinic  during  the  active  hours.     He  will  take  the 


CLINICS  175 

prescription,  measure  the  patient  for  size  of  frames, 
take  the  order  for  the  kind  of  frames,  and  then  bring 
the  finished  glasses  at  a  later  date,  on  which  the  patient 
is  told  to  return.  The  oculist  should  see  the  patient 
before  he  leaves  the  clinic  with  the  glasses,  to  make 
sure  that  the  lenses  are  right  and  the  frames  properly 
fitted.  Economical  rates  for  patients  and  satisfactory 
clinic  administration,  are  facilitated  by  such  arrange- 
ments. Payment  by  installment  should  be  arranged 
when  necessary.  Certain  patients  appear  who  have 
a  friend  or  relative  in  the  optical  business,  and  want 
to  have  him  provide  their  glasses.  This  should  be 
permitted  when  the  facts  are  clear  and  there  should 
be  an  understanding  with  the  optician  about  such 
cases  so  that  no  friction  will  eventuate. 

Letting  the  patients  go  to  any  outside  optician 
with  their  prescription  is  not  satisfactory.  There  is 
no  control  over  the  prices  charged,  and  it  is  difficult 
to  make  sure  that  patients  get  the  glasses  they  should. 
Sometimes  an  arrangement  is  made  with  a  single 
optician  outside,  the  patients  paying  the  Dispensary 
and  the  optician  sending  his  bill  at  agreed  prices. 
This  plan  obviates  one  difficulty,  but  does  not  meet 
others.  Not  nearly  as  many  patients  will  actually 
get  their  glasses;  and  it  is  also  much  more  difficult 
to  have  them  come  back  so  the  oculist  can  test 
them.  A  follow-up  system  to  be  sure  that  the  patient 
actually  secures  his  glasses  is  always  needed  in  an  Eye 
Clinic. 


176  DISPENSARIES 

Nose,  Throat  and  Ear  Clinic 

Some  institutions  have  a  separate  clinic  for  diseases 
of  the  ear,  but  the  growing  and  desirable  tendency  is 
to  treat  ear,  nose  and  throat  cases  in  one  clinic. 

A  history  room  is  necessary,  as  usual,  a  room  for 
testing  hearing,  and  an  examining  room  or  rooms 
which  may  best  be  divided  into  individual  booths, 
each  with  a  unit  equipment.  There  must  be  an 
operating  suite,  including  a  recovery  room,  unless  the 
operations  are  performed  elsewhere  in  the  Dispensary. 
It  is  no  longer  acceptable  to  operate  upon  the  tonsils 
without  keeping  the  patient  until  the  next  morning, 
at  least.  Some  Dispensaries  separate  from  a  hospital 
have  special  beds  for  this  over-night  care.  The  out- 
patient department  of  a  hospital  should  have  pro- 
vision in  the  House  for  such  cases.  Tonsillectomy 
performed  on  adults  frequently  requires  a  longer 
period  of  stay.  As  in  the  Surgical  Clinic,  it  is  a 
desirable  rule  that  no  operation  shall  be  performed 
unless  the  Chief  of  the  department  has  seen  the  case 
and  given  his  approval.  It  is  generally  desirable  for 
the  tonsillectomy  cases  to  remain  in  the  recovery 
room  of  the  clinic  for  one  to  three  hours  before  trans- 
ference to  the  ward.  It  is  particularly  undesirable 
to  have  such  patients  carried  through  corridors  where 
many  are  waiting,  for  the  patient's  appearance  while 
recovering  from  ether  may  shock  many  who  may  be 
expecting  to  pass  through  the  same  ordeal  themselves. 

Each  booth  of  the  examining  room  should  contain 
(1)  a  chair  and  a  stool  for  a  doctor  and  a  patient;  (2) 
an  instrument  table  with  instruments;  (3)  the  neces- 


CLINICS  177 

sary  lighting  for  the  surgeon^s  head  mirror;  and  (4) 
an  enameled  or  agate  pail  for  refuse  and  expectoration. 
Better  than  the  pail,  but  much  more  expensive,  is  a 
flushing  basin  with  running  water  connections.  (5) 
An  individual  instrument  sterilizer  (best  electric)  for 
each  booth  is  a  great  convenience  also. 

The  Throat  Clinic  of  course  requires  a  trained  nurse, 
and  a  large  clinic  needs  a  nurse  or  trained  attendant 
in  the  examining  room  and  a  nurse  in  the  operating 
room.  Operations  should  usually  be  done  by  appoint- 
ment, and  can  be  put  before  or  after  the  usual  clinic 
hours.  This  will  economize  space  and  nursing  service. 
Definite  records  of  appointment  should  be  kept,  and 
a  follow-up  system  for  these  as  well  as  for  the  chronic 
non-operative  cases.  As  a  rule  the  proportion  of 
cases  needing  social  service  is  not  large  enough  to 
require  a  special  social  worker  for  the  clinic.  The 
school  nurse  should  be  held  responsible  for  seeing  that 
her  children  keep  their  appointments  and  report  for 
after-care  as  required. 

Dental  Clinic 

The  diagnostic  importance  of  the  dentist  to  General 
Medicine,  Pediatrics,  etc.,  is  so  great  as  to  render  a 
Dispensary  incomplete  without  a  Dental  Department. 
There  is  also  a  mass  of  routine  dental  work  to  be  done 
which  usually  far  exceeds  the  facilities  in  the  com- 
munity, and  leads  to  numbers  of  undesirable  ^^  dental 
parlors.''  Dental  Clinics  in  well-conducted  Dispen- 
saries should  take  the  place  of  these. 

The  Dental  Clinic  requires  at  least  two  rooms,  if 


178  DISPENSARIES 

there  is  more  than  a  single  dentist  and  one  chair. 
The  extraction  and  other  operative  work  should  be 
performed  in  one  room.  If  there  are  a  number  of 
dental  chairs  and  several  dentists,  it  is  well  to  have 
one  large  room  for  cleaning,  filling,  etc.,  and  a  smaller 
room  for  the  extracting  and  operating.  Large  clinics 
will  increase  these  units.  A  recovery  room  for 
patients  immediately  after  extraction  or  other  opera- 
tions is  desirable  unless  elsewhere  accessible.  In  all 
but  very  small  clinics,  a  clerk  is  essential  to  attend  to 
the  executive  details  and  be  responsible  for  the  ar- 
rangement and  care  of  instruments  and  supplies. 
The  development  of  specially  trained  ^^  dental  hygien- 
ists,"  or  '^nurses"  for  prophylactic  work,  is  proceeding, 
and  they  will  doubtless  be  attached  to  dental  clinics 
in  the  future. 

The  equipment  of  a  Dental  Clinic  involves  con- 
siderable expense.  A  clinic  with  four  chairs,  of 
modern  but  not  elaborate  type,  with  water  connection; 
electric  dental  engines,  and  a  set  of  routine  instru- 
ments and  trays  for  each  chair,  would  cost  about 
$1,500.  If  more  than  emergency  work  is  done,  a 
follow-up  system  is  quite  important,  and  patients 
should  be  taught  to  come  to  the  dentist  regularly  at 
intervals  indicated  by  him.  Fees  are  usually  charged 
to  cover  the  cost  of  the  materials  used.  A  problem 
arises  in  connection  with  the  taking  of  plates,  making 
false  teeth,  doing  crown  and  bridge  work,  etc.  The 
equipment  for  these  is  beyond  the  reach  of  any  but 
large  dental  infirmaries,  yet  adults  frequently  demand 
them.     A  clinic  can,  however,  arrange  with  an  out- 


CLINICS  179 

side  dental  laboratory  to  furnish  plates  and  teeth, 
only  the  taking  of  the  casts  being  done  in  the  clinic. 

Dermatology 

Physicians  who  confine  their  practice  to  skin  dis- 
eases will  usually  be  found  only  in  the  largest  cities. 
A  Dermatological  Clinic  under  those  conditions  may 
be  maintained  either  independently,  or  combined 
with  syphilis  (page  168).  Otherwise  it  may  be  made 
part  of  general  medicine,  so  far  as  adults  are  concerned, 
and  of  pediatrics  with  respect  to  children,  a  physician 
especially  interested  in  skin  diseases  being  detailed 
to  treat  skin  cases,  as  a  division  of  the  two  clinics 
mentioned.  Dermatological  work  needs  good  day- 
light. No  artificial  lighting  is  wholly  satisfactory. 
The  careful  dermatologist  in  an  evening  clinic  will  refer 
questionable  cases  by  appointment  to  a  daylight  hour. 

Facilities  for  X-ray  and  for  radium  treatments 
should  be  available  when  possible. 

In  a  Dermatological  Clinic  there  should  be  a  history 
room  and  one  examining  room  for  each  physician  who 
is  on  service.  Unless  the  clinic  is  closely  adjacent  to 
a  laboratory,  there  should  be  provision  in  the  clinic 
for  the  dermatologist  to  use  a  microscope  and  to  make 
other  tests  on  skin  lesions  or  specimens.  Careful 
attention  to  social  conditions,  and  good  follow-up 
work,  is  necessary  for  cases  of  scabies  and  other  infec- 
tious skin  diseases. 

Syphilis 

The  great  variety  of  local  symptoms  arising  out  of 
this  disease  cause  patients  to  appear  in  every  depart- 


180  DISPENSARIES 

ment  of  a  Dispensary,  with  symptoms  which  are 
really  the  result  of  syphilis.  For  the  sake  of  clinical 
effectiveness  in  diagnosis  and  treatment,  and  for  the 
protection  of  the  public  health,  it  is  essential  that 
every  Dispensary  lay  down  the  rule  that  all  syphilis 
be  the  responsibility  of  a  single  department.  Whether 
this  department  shall  be  a  special  clinic  for  syphilis, 
or  a  Genito-Urinary  Department  treating  syphilis 
and  gonorrhea,  or  whether  it  shall  be  a  Department 
of  Dermatology  and  Syphilis,  is  a  matter  for  detailed 
consideration. 

The  department  where  is  placed  the  responsibility 
for  the  treatment  of  syphilis  must  depend  on  the 
oculist  to  help  with  an  eye  condition,  the  surgeon, 
perhaps,  with  a  syphilitic  ulcer,  the  Medical  Clinic 
with  a  heart  condition,  the  Children's  Clinic  with  a 
difficult  feeding  case  of  congenital  syphilis.  The  Neu- 
rological Department  must  have  jurisdiction  over  its 
special  manifestations  of  the  disease. 

A  few  institutions  have  attempted  to  form  a  Syphilis 
Clinic  which  is  practically  a  department  of  general 
medicine  in  itself,  including  specialists  in  ophthal- 
mology, neurology,  internal  medicine,  etc.,  but  this 
plan  will  be  practical  only  in  a  few  large  teaching 
institutions  and  cannot  be  generally  expected  or 
recommended.  These  general  principles  should  be 
laid  down: — (1)  Concentrate  the  responsibility  for 
syphilis  in  a  single  department ;  (2)  let  its  local  mani- 
festations  or  symptoms  be  examined  or  treated  in 
those  clinics  to  which  they  especially  relate;  but  (3) 
require  the  patient  to  report  for  constitutional  treat- 


CLINICS  181 

ment  at  periodic  intervals,  as  required  by  the  condi- 
tion, to  the  department  having  the  general  respon- 
sibility for  syphilis.  The  department  having  the 
primary  responsibility  for  syphilis  will  thus  carry  all 
syphilitic  patients  on  its  follow-up  system,  but  some 
of  the  same  patients  will  also  be  carried  by  other 
clinics.  This  relationship  is  particularly  important  in 
dealing  with  cases  of  neuro-syphilis. 

One  means  of  enforcing  these  principles  in  practice 
is  through  the  requirement  that  the  Wassermann 
test  shall  be  done  only  through  a  single  department, 
e.g.,  the  central  laboratory,  and  that  the  occurrence 
of  a  positive  Wassermann  (or  any  other  test  which 
indicates  syphilis)  shall  automatically  cause  a  patient 
to  be  transferred  to  the  department  having  the  pri- 
mary responsibility  for  syphilis,  the  patient  being 
placed  on  the  follow-up  system  of  the  Syphilis  De- 
partment. 

A  Syphilis  Clinic  needs  as  good  light  as  a  Dermato- 
logical.  There  must  be  a  history  room,  an  examining 
room  for  each  physician  on  service,  and  a  special 
room  for  the  administration  of  salvarsan.  The  staff 
must  have  facilities  for  Wassermann  tests,  and  a 
dark  field  microscope  for  examination  of  primary 
lesions.  The  main  Laboratory  of  the  Dispensary 
may  provide  these  facilities.  In  many  institutions 
the  Wassermann  tests  will  be  performed  at  the  labora- 
tory of  the  Municipal  or  State  Department  of  Health, 
but  the  clinic  itself  must  provide  for  the  diagnosis  of 
early  cases.  The  growing  importance  of  lumbar 
puncture  in  the  diagnosis  of  syphilis  of  the  central 


182  DISPENSARIES 

nervous  system  renders  it  essential  to  have  facilities 
for  this.  There  is  still  some  difference  of  opinion  as 
to  how  far  it  is  safe  to  perform  lumbar  puncture  as  an 
out-patient  procedure,  the  patient  going  from  the 
building  shortly  after  the  operation.  Many  clinics  of 
standing  have  had  excellent  results  and  no  serious 
drawbacks  from  the  performance  of  lumbar  puncture 
in  this  way.  But  some  selection  of  cases  must  be 
made  and  it  is  desirable  to  have  facilities  for  keeping 
patients  over  night,  although  they  need  not  be  util- 
ized for  every  patient. 

A  nurse  is  needed  to  assist  in  salvarsan  injections, 
and  may  be  made  an  expert  assistant  in  this  technique. 
The  nurse,  or  a  woman  attendant,  should  of  course  be 
present  at  those  examinations  of  female  patients 
where  exposure  of  the  body  is  necessary.  Nowhere 
is  a  social  worker  more  important  than  in  a  clinic 
treating  syphilis,  for  the  most  difficult  and  complex 
family  problems  arise.  The  follow-up  system  assumes 
large  proportions  in  a  syphilis  clinic  owing  to  the 
protracted  period  of  treatment,  and  in  a  large  clinic 
needs  a  special  clerk. 

Syphilis  and  gonorrhea  are  distinct  in  diagnosis 
and  procedure  of  treatment,  but  have  a  close  relation- 
ship from  the  public  health  standpoint.  When  the 
two  diseases  are  not  dealt  with  by  the  same  clinic,  a 
satisfactory  relationship  between  the  two  or  three 
clinics  treating  them  must  be  worked  out.  A  con- 
siderable proportion  of  the  gonorrhea  cases  are  in- 
fected with  syphilis  and  yet  this  may  be  overlooked 
unless  special  plans  are  made.     The  taking  of  routine 


CLINICS  183 

Wassermann  tests  of  all  patients  coining  with  gonor- 
rhea is  to  be  encouraged.  Some  system  should  be 
worked  out  in  every  Dispensary  for  co-operation  on 
all  the  public  health  relationships  of  venereal  disease, 
as,  for  example,  by  a  joint  committee  of  members  of 
the  staff  of  the  different  departments  (one,  two  or 
three  in  number),  treating  syphilis  and  gonorrhea. 
The  common  elements  which  relate  these  diseases  to 
the  community  can  then  be  dealt  with  according  to  a 
single  carefully  worked  out  and  uniform  policy. 

Tuberculosis 

This  disease  is  largely  referred  to  in  connection  with 
public  health  work,  but  a  word  must  be  said  on  its 
place  in  the  general  Dispensary.  A  special  clinic  for 
tuberculosis  should  be  conducted  as  a  Public  Health 
Dispensary  clinic,  whether  it  is  in  a  general  Dispensary 
or  not.  Some  large  Dispensaries  in  cities  will  have 
no  Tuberculosis  Clinic  because  the  Department  of 
Health  or  some  other  institution  has  one  in  the  neigh- 
borhood, as  part  of  the  general  system  of  Tuberculosis 
Clinics  in  the  community.  It  is  most  desirable  that 
one  of  the  tuberculosis  clinics  which  belong  to  such  a 
system  shall  be  located  in  the  general  Dispensary. 
Tuberculosis  will  appear  frequently  in  any  Dispensary, 
and  in  several  departments,  particularly  the  General 
Medical,  Children's,  Surgical  and  Orthopedic.  When 
there  is  no  special  Tuberculosis  Clinic,  the  major 
portion  of  pulmonary  tuberculosis  will,  of  course, 
appear  in  the  Medical  Department  for  adults.  In 
view  of  the  great  importance  of  the  disease,  it  is  to  be 

13 


184  DISPENSARIES 

desired  that  there  be  a  definite  system  by  which  a 
physician  especially  skilled  in  its  diagnosis  shall,  as 
a  member  of  the  General  Medical  Department,  have 
all  cases,  or  at  least  all  questionable  cases,  referred  to 
him.  There  should  furthermore  be  a  very  carefully 
worked  out  system  by  which  patients  will  be  re- 
ferred for  treatment  and  follow-up  to  the  appropriate 
public  health  dispensary.  Social  Service  and  visiting 
nursing  are  essential  adjuncts  of  effective  tuberculosis 
work. 

Diagnostic  Departments 

The  Laboratory  and  the  X-ray  Department  are 
not  clinics,  but  are  primarily  aids  to  diagnosis. 

Laboratory 

In  a  Laboratory  for  a  Dispensary  the  minimum 
facilities  provided  should  be : — Urine  tests,  qualitative 
and  quantitative,  chemical,  and  bacteriological;  blood 
counts;  Widal  tests;  the  simpler  bacteriological  exam- 
inations, especially  sputum  examinations,  throat  cul- 
tures; examination  of  smears  for  the  gonococcus 
organism;  Wassermann  tests  and  complement-fixation 
tests  for  gonorrhea;  examination  of  stomach  and 
intestinal  contents. 

Facilities  for  the  examination  of  pathological  tissues 
are  essential  in  connection  with  certain  forms  of 
surgical  out-patient  work,  but  such  clinics  will  usually 
have  access  to  the  Pathological  Laboratory  of  a 
hospital. 

In  a  hospital  of  moderate  size,  the  main  Laboratory 
of  the  hospital  will  serve  for  the  out-patient  depart- 


CLINICS  186 

ment;  but  a  local  Laboratory  for  the  frequently  per- 
formed routine  tests,  particularly  of  urine  and  blood, 
should  usually  be  provided,  unless  the  main  Labora- 
tory is  very  accessible. 

For  the  Laboratory  of  a  Dispensary  treating  a 
hundred  or  more  patients  a  day,  the  apparatus  should 
include  sterilizing  equipment,  incubator,  ice  chest, 
bench  and  sinks  adapted  for  convenient  work,  the 
necessary  reagents  and  glassware,  a  microscope,  good 
daylight,  facilities  for  work  by  artificial  light,  a  dark 
stage  attachment,  and  the  necessary  microscopic  acces- 
sories, etc.  The  full  equipment  for  a  small  Laboratory 
of  this  type  would  cost  $1,000  to  $1,200.  Fre- 
quently the  Laboratory  of  the  local  or  the  State  De- 
partment will  do  free  of  charge  the  examinations  of 
sputa,  throat  or  vaginal  smears,  Widal  and  Wasser- 
mann  tests.  One  room,  14  x  20,  will  suffice,  but  it  is 
better  to  have  two,  one  at  least  14  x  16,  and  one  smaller 
room  of  about  10  x  12.  The  Laboratory  Staff  must 
include  a  well-trained  pathologist.  In  a  Dispensary 
which  carries  on  only  one  set  of  chnics  daily,  he 
may  be  on  part  time.  In  a  large  Dispensary,  it  is 
practically  essential  that  there  be  a  paid  technician, 
on  full  time  duty. 

It  is  hardly  possible  to  overestimate  the  stimulating 
influence  of  good  Laboratory  work  upon  the  clinicians 
of  a  Dispensary.  The  personahty  of  the  Pathologist 
as  well  as  his  equipment  is  an  important  factor  in 
developing  the  usefulness  of  the  Laboratory  to  its 
fullest  capacity. 


186  DISPENSARIES 

X-ray  Department 

The  X-ray  Department  is  used  to  some  extent  for 
therapeutic  purposes,  but  its  major  service  is  in 
diagnosis.  The  cost  of  the  needed  equipment  can 
hardly  be  below  $2,500,  and  more  satisfactory  results 
may  be  expected  for  $3,000  or  over.  An  out-patient 
department  will  be  served  by  the  same  X-ray  equip- 
ment as  that  used  for  the  House  cases.  A  large 
majority  of  all  X-ray  cases  are  ambulatory  patients. 
The  full  details  of  X-ray  equipment  given  in  several 
standard  works  relating  to  hospitals  renders  detail 
unnecessary  here,  but  something  may  be  said  on  the 
administrative  aspects. 

The  large  institutions  may  expect  to  have  a  roent- 
genologist who  specializes  in  this  work,  and  who  will 
have  one  or  more  assistants,  either  physicians  or 
lay  technicians.  The  use  of  lay  technicians  for  operat- 
ing machines  under  medical  direction  is  increasing. 
In  the  small  institutions,  the  problem  of  a  Staff  for 
the  X-ray  Department  is  often  a  difficult  one.  The 
expense  of  X-ray  service  is  too  great  for  the  average 
patient  at  a  charitable  dispensary,  to  meet  more  than 
a  fraction  of  the  cost  of  taking  and  developing  a  plate. 
At  prices  of  supplies  such  as  prevailed  before  the  war, 
the  cost  per  plate  generally  ranged  from  35  to  50  cents 
for  a  5  X  7  plate  to  $1.00  to  $1.25  for  a  14  x  17  size, 
these  figures  including  allowances  for  salaries  and  for 
depreciation  of  equipment  as  well  as  materials  used. 
Fees  of  50  cents  or  $1.00  per  plate  will  have  to  be 
remitted  for  a  considerable  proportion  of  dispensary 
patients  at  most  institutions. 


CLINICS  187 

The  financial  burden  can  be  lightened  and  an  addi- 
tional service  rendered  by  combining  with  the  chari- 
table work  a  Consultation  Division  of  the  X-ray 
Department.  There  are  of  course  many  private 
patients  of  physicians  who  can  afford  good  fees  for 
X-ray  service.  There  are  also  a  large  number  of 
persons  in  every  community  who  can  afford  to  pay 
their  physician,  but  who  cannot  afford  to  pay  high 
fees  for  X-rays.  The  usual  private  rates  for  radiog- 
raphy are  beyond  them.  The  X-ray  Department 
of  a  hospital  or  Dispensary  should  be  open  to  such 
patients,  when  referred  by  their  physician — brought 
in  by  him  personally  or  sent  with  a  letter.  The  fees 
charged  should  sufficiently  cover  the  full  cost.  The 
patients  should  be  sent  back  to  their  physicians  with 
the  X-ray  plates.  Such  a  use  of  the  X-ray  Depart- 
ment is  of  very  considerable  service  to  patients;  it  is 
a  benefit  to  the  local  medical  profession,  and  it  will  be 
of  substantial  assistance  to  the  finances  of  the  X-ray 
Department. 

Treatment  Departments 

Out  of  the  Pharmacy  sprang  the  title  '^  Dispensary," 
but  with  the  advance  of  medical  science  and  the 
relatively  diminishing  use  of  drugs,  the  Pharmacy  has 
sunk  to  a  minor  place.  But  its  function  is  still  highly 
important. 

In  even  a  small  Dispensary  a  licensed  graduate 
pharmacist  must  be  in  charge,  although  in  the  out- 
patient department  the  drugs  may  be  compounded 
in  the  hospital  Pharmacy  and  brought  to  the  Dispen- 
sary merely  for  giving  out.     In  a  large  Dispensary,  the 


188  DISPENSARIES 

Pharmacy  should  be  located  in  the  admission  hall 
so  as  to  be  most  accessible,  and  it  should  be  con- 
venient to  the  exits,  as  a  majority  of  patients  going 
to  the  Pharmacy  do  so  when  they  are  through  in  the 
clinics  and  ready  to  leave  the  building.  The  window, 
or  counter,  whence  the  drugs  are  delivered,  must  be 
located  with  these  conditions  in  mind.  There  must 
be  waiting  space  for  patients,  but  it  is  not  necessary 
to  have  seats  for  the  total  number  of  patients  who 
may  be  expected  to  wait  at  the  Pharmacy  at  one  time. 
With  sufficient  staff,  few  cases  need  wait  long  for 
their  prescriptions.  Some  seating  space  is  essential. 
The  prescription  blanks  used  should  be  such  as  will 
minimize  the  risk  of  error  in  giving  out  medicines. 
Most  Dispensaries  will  use  a  formulary,  so  that 
physicians  will  put  down  merely  a  letter  or  a  number 
designating  one  of  the  more  usual  prescriptions,  the 
contents  of  the  prescription  being  specified  on  a 
printed  list,  which  is  in  the  possession  of  the  Pharmacy 
and  of  each  physician  (also  posted  in  each  clinic). 
These  stock  prescriptions  are  usually  compounded  in 
quantity,  and  dispensed  from  large  containers  as 
required.  A  formulary  saves  much  time,  but  should 
not  prevent  other  medicines  or  prescriptions  being 
secured.  Formularies  should  be  periodically  revised. 
It  should  be  a  general  rule,  in  the  interest  of  economi- 
cal and  wise  use  of  medicine,  that  not  more  than  one 
week's  supply  should  be  given  a  patient  except  in 
unusual  cases.  It  must  be  borne  in  mind,  however, 
that  patients  who  do  not  need  to  return  to  see  the 
doctor  for  two  weeks  or  more,  and  who  live  at  a  dis- 


CLINICS  189 

tance,  may  properly  be  given  a  larger  amount  of 
needed  medicines. 

Providing  accurate  and  easily  understood  directions 
with  the  medicine  is  essential.  The  use  of  the  phrase 
*'as  directed'^  on  the  label  should  be  forbidden. 
Directions  should  be  printed,  stamped,  or  plainly 
written  on  a  suitable  label  or  elsewhere  on  the  con- 
tainer, and  the  patient  should  be  instructed  verbally 
how  to  take  the  medicine.  Any  question  from  him 
should  be  answered.  Unless  these  requirements  are 
carefully  attended  to,  much  of  the  benefit  of  medicine 
furnished,  particularly  to  ignorant  patients,  will  be  lost. 

A  Pharmacy  needs  a  fairly  generous  allotment  of 
space,  but  it  is  often  practicable  to  put  on  the  main 
floor  only  a  comparatively  small  room  for  dispensing, 
while  the  compounding  room  is  either  that  of  the 
hospital  Pharmacy,  or  is  on  the  basement  floor  of  the 
Dispensary,  connected  with  the  dispensing  room  by 
a  stairway  and  dumb-waiter.  Comparatively  little 
work  may  have  to  be  done  in  the  compounding  room 
during  the  active  period  of  the  clinics.  Where  two 
sets  of  clinics  are  run  daily,  there  must  be  additional 
provision  in  the  Pharmacy  staff  to  keep  up  with  the 
work. 

If  fees  are  charged  for  medicines,  according  to 
principles  laid  down  in  other  chapters,  it  may  be 
expected  that  at  least  the  cost  of  all  the  materials, — 
drugs,  bottles  and  other  containers — will  come  back. 
Probably  somewhat  more  may  be  returned,  even 
though  no  patient  is  refused  medicine,  at  reduced  rate 
or  free,  when  he  cannot  pay  the  regular  fee« 


190  DISPENSARIES 

Massage 

The  value  of  this  department  is  considerable  if  well 
conducted.  For  equipment  merely  tables  are  re- 
quired. There  must  be  privacy,  as  exposure  of  the 
body  is  often  necessary.  The  rooms  used  for  a  Medi- 
cal Clinic  are  well  adapted  to  massage,  if  it  is  neces- 
sary to  make  a  combination  and  use  the  same  rooms 
at  different  hours  for  two  purposes. 

Electro-Therapeutic  Department 

Not  infrequently  the  Neurological  Clinic  has  ap- 
paratus for  treatment  by  electricity  in  various  forms, 
but  sometimes  this  is  put  in  a  separate  division  or 
department.  The  development  and  value  of  electro- 
therapeutic  treatment  will  depend  chiefly  on  the 
presence  of  a  physician  who  is  particularly  interested 
and  expert  in  its  use.  With  such  a  man  it  proves  well 
worth  while,  providing  the  somewhat  expensive 
apparatus  is  available.  Not  very  much  floor  space 
is  required. 

Zander  and  Physical  Gymnastics 

A  full  outfit  for  Zander  treatment  is  expensive  and 
needs  special  direction  by  an  expert.  Physical 
gymnastics  adapted  to  the  correction  of  various 
defects,  as  of  posture,  or  for  strengthening  muscles 
undeveloped  because  of  paralysis  or  other  causes,  are 
much  more  easily  provided  by  small  institutions. 
The  Orthopedic  Department,  with  its  special  interest 
in  those  defects  which  can  be  dealt  with  by  physical 
gymnastics,  may  often  be  able  to  supervise,  or  even 


CLINICS  191 

train  a  special  technician  for  this  service.  The  War 
will  undoubtedly  lead  to  a  considerable  increase  in  the 
number  of  persons  who  are  skilled  in  medical  gymnas- 
tics. The  equipment  required  can  cost  anything  from 
a  small  sum  to  a  very  large  amount,  but  a  competent 
person  can  secure  excellent  results  in  certain  troubles 
of  children, — postural  and  structural  defects,  muscu- 
lar atrophies,  etc., — with  very  simple  apparatus. 

Hydrotherapy 

The  special  value  of  such  a  department  in  connec- 
tion with  neurological  and  psychiatric  institutions  is 
well  recognized;  but  its  field  is  much  broader.  Instal- 
lations are  expensive  and  a  specially  trained,  compe- 
tent person  must  be  in  charge. 

Operation  of  Treatment  Departments 

One  essential  principle  must  be  borne  in  mind  in 
operating  the  treatment  departments.  They  ordi- 
narily take  no  patients  from  the  dispensary  admission 
desk,  but  receive  them  only  on  reference  from  other 
clinics.  It  is  essential  that  the  patient  should  report 
back  to  the  physician  or  surgeon  who  referred  them  to 
the  treatment  department,  at  such  periodical  inter- 
vals as  he  indicates.  A  definite  system  to  effectuate 
such  reporting  must  be  worked  out.  Records  must 
be  kept  in  the  treatment  department,  indicating 
what  has  been  done  at  each  visit  paid  by  the  patient, 
and  the  result  of  the  examination  by  the  surgeon  or 
physician  in  charge  of  the  case  must  be  entered  there, 
as  well  as  on  the  record  of  the  case  in  the  referring  clinic. 


192  DISPENSARIES 


CHAPTER   XII 

THE    MANAGEMENT    OF   A   DISPENSARY   ADMIT- 
TING  SYSTEM 

Many  of  the  problems  of  admitting  patients  and 
of  managing  records  and  statistics  are  the  same  in 
every  Dispensary,  whether  it  be  a  large  pay  clinic, 
like  the  Mayo  Clinic,  or  a  charitable  Dispensary  treat- 
ing only  the  very  poor.  Methods  must  of  course  be 
adapted  to  the  social,  as  well  as  the  medical  charac- 
teristics of  the  clientele.  This  chapter  will  relate 
chiefly  to  the  conditions  ordinarily  found  in  chari- 
table Dispensaries,  and  the  adaptations  necessary  for 
large  Dispensaries  of  other  types  will  readily  suggest 
themselves.  The  problem  of  the  small  Dispensary  is 
treated  separately  (pages  282-296). 

In  a  large  Dispensary,  every  day  brings  a  human 
stream.  A  hundred,  maybe  a  thousand,  men,  women 
and  children,  will  pass  through  the  portals  within  a 
few  hours.  Each  one  brings  his  problem.  It  may 
be  only  a  child  whose  teeth  need  cleaning,  or  it  may  be 
a  girl,  alone  in  the  world,  who  is  bearing  the  burden 
of  unmarried  maternity ;  or  a  baby  with  pneumonia,  a 
working  man  with  a  cut  hand,  a  woman  with  symp- 
toms which  may  prove  trivial  or  which  may  be  cancer; 
people  whose  hearts,  stomachs,  or  nerves  have  gone 
wrong;  people  whose  eyes,  throats  or  ears  need  atten- 
tion to  make  them  work  right ;  people  who  have  never 


ADMISSION  SYSTEM  193 

known  anything  but  dire  poverty;  people  for  whom 
a  sudden  misfortune  has  wrecked  former  comfort; 
people  who  can  pay  their  way  usually  and  who  wish 
to  do  so  always,  but  whose  resources  break  under  the 
emergency  of  sickness.  The  medical  and  social  prob- 
lems which  may  be  found  in  five  hundred  units  of  the 
human  stream  that  rolls  through  the  dispensary  doors 
are  as  varied  as  life  itself. 

Too  often,  the  reception  of  these  vivid  human  units 
at  a  Dispensary  has  been  left  in  the  hands  of  a  clerk 
who  assigns  them  hastily  to  the  clinics.  This  is 
wrong.  As  an  old  proverb  says,  to  save  at  the  gate  is 
to  suffer  in  the  house.  Careful,  thoughtful  admission 
of  patients  by  trained  hands  promotes  the  medical 
and  social  efficiency  of  the  entire  institution. 

The  functions  of  a  properly  organized  admitting 
system  are: 

1.  Social  Placement,  i.e.,  deciding  as  to  the  economic  and 
social  condition  of  each  patient  (or  family).  This  renders 
possible  (1)  decision  whether  the  patient  should  be  treated 
in  a  free  clinic,  a  pay  clinic  or  a  private  office;  (2)  determina- 
tion of  the  fee  to  be  charged  or  remitted ;  (3)  indicating  any 
outstanding  social  need  and  starting  to  alleviate  it. 

2.  Medical  Placement,  i.e.,  assigning  each  patient  to  the 
clinic  appropriate  to  his  complaint.  This  also  involves  the 
exclusion  of  diseases  not  accepted  for  treatment  in  the  par- 
ticular Dispensary, — e.g.,  the  common  contagious  diseases 
of  children. 

3.  Identification.  Securing  and  keeping  accurate  identi- 
fying data  for  each  individual. 

4.  Collection  of  Fees,  if  fees  are  charged. 

5.  Statistics  of  Attendance.     These  are  natm-ally  made 


194  DISPENSARIES 

at  the  admission  desks,  and  should  be  part  of  the  responsi- 
bility of  the  admission  system. 

Two  additional  functions  are  so  closely  connected 
with  these  that  they  may  well  be  included  under  the 
duties  of  the  Admission  Department,  viz. : 

6.  Custody  of  Records.  The  clinical  and  other  records 
concerning  patients  may  be  filed  and  cared  for  by  this 
department. 

7.  Inquiries.  Requests  for  records  or  information  con- 
cerning patients  should  be  looked  into  by  this  department, 
and  the  superintendent  or  other  official  supplied  with  the 
data  required  for  an  answer. 

This  group  of  functions  makes  a  body  of  naturally 
coherent  duties  which  even  in  a  small  Dispensary  will 
call  for  the  time  of  one  competent  person,  and  in  a 
large  institution  will  demand  a  staff  of  several  per- 
sons under  a  well-trained  departmental  head.  Part 
of  the  common  failure  in  dispensaries,  i.e.,  to  secure 
wise  admissions,  full  and  accurate  statistics,  and  care- 
ful filing  of  records,  has  been  due  to  failure  to  combine 
related  duties  so  as  to  make  enough  of  a  job  to  render 
the  employment  of  a  trained  person  worth  while. 

The  admission  system  as  now  outlined  includes  two 
main  functions:  first,  admitting  proper;  and  second, 
the  closely  connected  function  of  recording  and  caring 
for  the  data  arising  out  of  the  admitting.  The  title 
of  ''Department  of  Admission  and  Registration''  may 
well  be  given  to  this  division  of  a  Dispensary's  work. 

The  procedure  of  admission  can  best  be  illustrated 
by  a  diagram  which  tells  its  own  story: — • 


ADMISSION  SYSTEM 


195 


TO  CLINICS 


It  must  be  understood  that  the  arrangement  in 
this  sketch  is  wholly  diagrammatic ;  the  actual  placing 
of  the  desks,  record  room,  etc.,  in  a  Dispensary  are  not 
indicated,  only  their  relationships.  The  actual  spac- 
ing must  be  governed  by  the  floor  plan  of  the  admis- 
sion hall;  but  the  essential  order  and  relations  of  the 
different  parts  must  be  preserved  if  satisfactory  work 
is  to  result. 

The  actual  operation  of  the  admission  system  is 
greatly  facilitated  by  a  well-designed  set  of  cards  and 


196 


DISPENSARIES 


forms.  A  set  of  typical  forms,  printed  below  with  a 
few  words  of  explanation  for  each,  will  be  a  practical 
way  of  rendering  this  chapter  useful. 

FORMS  USED  IN  THE  ADMISSION  AND  REGISTRATION  SYSTEM 

OF  A  DISPENSARY 


Form  Designation        Used  At 
No. 
1     Distribu-        Desk  No.  1 
tion  sups 


2     Clinio 
SUps 


Desk  No.  2 


For  the  Purpose  of 

Dividing  the  incoming 
stream  into  (a)  Old  Pa- 
tients (b)  New  Patients 
(c)  Lost  ("ard  Patients, 
and  of  keeping  (b)  and 
(c)  in  order  of  arrival. 


Furnishing  a  memo- 
randum of  the  patients 
sent  to  each  cUnic,  and 
a  receipt  for  the  fee,  if 
a  fee  is  levied.  The 
numbers  on  the  slips 
enable  the  clinic  man- 
ager to  call  patients  in 
order  of  arrival;  and 
also  serve  to  give  the 
Registrar  immediate 
statistics  of  daily  clinic 
attendance. 


Remarks 

Slips  are  numbered  or  let- 
tered serially.  Numbers 
given  to  new  patients  en- 
able these  to  be  called  to 
the  Admission  Desk  in  or- 
der of  arrival.  Men  and 
women  may  be  separated, 
if  desired,  by  givmg  out 
numbers  in  odd  and  even 
series.  Lost  card  patients 
may  be  given  the  letter 
series. 

Patients  who  "know  the 
ropes,"  from  previous  vis- 
its, or  who  show  their  ad- 
mission cards  at  Desk  No.  1 , 
go  at  once  to  the  Cashier's 
Desk  (No.  2)  and,  after 
paying  a  fee,  if  such  is 
required,  receive  their  clinic 
slip,  which  they  must  show 
at  the  clinic  in  order  to  be 
admitted.  New  patients, 
after  being  passed  by  Desk 
4,  go  to  Desk  2  and  follow 
the  same  routine.  The  set 
of  slips  for  each  clinic  may 
be  numbered  from  1  up 
each  day,  or  in  a  cumula- 
tive series.  The  Cashier 
keeps  the  stub,  gives  the 
patient  the  slip,  stamping 
both  with  the  date  and  fee 

f)aid.  Clinic  slips  are  col- 
ected  at  the  end  of  each 
clinic  period.  By  counting 
the  stubs  and  the  slips, 
each  furnishes  a  check  upon 
the  other,  and  also  upon 
the  cash.  There  will  al- 
ways be  found  a  certain 
small  proportion  of  pa- 
tients who  elope, — jthat  is, 
get  their  clinic  slips  and 
even  pay  for  them,  but  for 
one  reason  or  another  fail 
to  go  to  the  clinic.  The 
stubs  from  these  patients 
will  be  found  but  not  the 
slips.  In  some  institutions, 
the  cash  register  has  been 
used.  This  is  a  convenience, 
but  does  not  furnish  any 
essential  check  upon  the 
cash. 


ADMISSION  SYSTEM 


197 


Admifleion     Desks  No.  4 
Card  (5,  etc.) 


4     Clinic 
Record 


Desk  No.  4 
in  Clinic  and 
Record  Room 


5    Index 
Card 


Record 
Room 


Fee   Re- 
mission 
Slip 


Desk  No.  4 
and  by  cer- 
tain ofi&cials 
of  Dispensary 


7    Free 
Pass 


Desk  No.  4 
and  by  cer- 
tain officials  of 
Dispensary 


Serving  the  patient  as 
a  voucher  for  his  admis- 
sion (and  first  fee,  if 
any) ;  enabling  him  to 
show  this  at  later  visits, 
giving  patient  informa- 
tion, in  some  cases,  as 
to  hours,  days,  or  rules 
of  clinics. 


Recording  the  medical 
record  of  the  patient 
and  certain  personal 
and  social  data.  A  per- 
manent record. 


Constituting  an  index 
(alphabetical)  to  all 
patients  who  have  been 
treated  in  the  Dispen- 
sary at  any  time. 


Remitting  a  fee,  in 
whole  or  part.  Good 
on  one  day  only.  It  is 
wise  not  to  print  on  the 
slip  the  words  "Fee 
Remission,.' '  or  the  like, 
but  to  use  a  distinguish- 
ing color.  Similarly 
with  No.  7. 


Enabling  a  patient  to 
secure  a  series  of  fee  re- 
missions for  a  specified 
period  during  which  it 
is  judged  such  remis- 
sions are  necessary. 


Issued  to  patient  at  first 
visit,  after  inquiry  at  ad- 
mission desk.  Numbered 
serially,  the  number  being 
that  under  which  all  the 
patient's  clinic  records  are 
filed.  If  lost  by  an  old 
patient,  is  reissued  with 
former  number.  The  card 
should  be  of  board  or  linen 
so  as  to  be  durable. 

Data  above  second  red  line 
filled  out  at  Desk  No.  4  at 
patient's  first  visit.  Serial 
number    the    same    as    on 

Satient's  admission  card, 
ledical  record  filled  out  in 
clinic.  A  patient  treated 
also  in  other  clinics  may 
have  a  separate  card  for 
each  clinic,  but  aU  are  filed 
in  Record  Room  under 
same  number. 

Filled  out  from  the  data 
taken  at  Desk  4 ;  filed  alpha- 
betically in  Record  Room. 
In  the  form  shown,  the 
data  are  copied  out  (prefer- 
ably typewritten)  from  the 
upper  half  of  the  clinic 
record,  the  copying  being 
done  after  the  clinics  are 
over  for  the  day  and  the 
records  have  come  back  to 
the  Record  Room. 

Issued  by  Registrar  or  ad- 
mitting officers,  or  by  social 
workers  or  other  officials 
authorized  to  sign  them. 
Shown  by  patient  at  Desk 
2,  and  accepted  by  cashier 
in  lieu  of  fee.  Cashier 
stamps  cUnic  slip  and  stub 
for  the  amount  paid,  or  as 
"Free"  and  keeps  the  Re- 
mission Slip  with  the  stub 
as  a  cashier's  voucher. 

Used  as  No.  6,  except  that 
patient  retains  the  Pass, 
until  its  expiration.  At 
each  visit,  on  presenting  the 
Pass  to  the  proper  officer  a 
fee  remission  slip  is  given 
out,  for  use  on  that  day. 
Free  passes  are  rarely  to  be 
given  for  more  than  one 
month;  a  re-inquiry  being 
then  made  before  renewal. 


198 


DISPENSARIES 


Form  No.  1 


A  Dispensary  re- 
ceiving only  twenty- 
five  patients  a  day  can 
use  all  these  forms  to 
advantage,  except 
No.  1,  which  will  be 
needed  only  when  the 
number  of  patients  in 
a  two-hour  admission 
period  exceeds  one 
hundred.  As  will  be 
shown  in  Chapter 
XIII,  this  system  prac- 
tically keeps  the  sta- 
tistics of  attendance 
of  the  Dispensary  with 
a  minimum  of  labor  in 
counting.  It  also 
furnishes  a  daily  check 
on  the  cash  received 
from  fees. 

So  far  as  possible, 
all  fees  should  be  col- 
lected at  the  cashier's 
desk  in  the  Admission 
Hall.     In  some  cases 


it  is  con- 
venient to 
have  fees 
collected  in 
the  clinic, 
e.g.,  a  pa- 
tient may 
have  to  be 
in  the  den- 
tist's chair 
before  the 
character 


Children's 

Room  310       3rd  Floor 


Date ^... 

Paid ^... 

No 

CHILDREN'S 

Room  310 


Form  No.  2 


ADMISSION  SYSTEM  199 


DISPENSARY 

Street, 


Patient's  Name Age. 

No. _ Address 


Dept Date. 

Dept Date. 

Dept-... _ Date. 

Dept...... _ „...  Date. 

Dept _ , Date.. 

Dept Date. 

Dept .-. Date. 

Morning  Clinics 
Hours  _        .       ^,.    . 

Evening  Clinics 


KEEP 
THIS 
CARD 

If  you  do, not  bring 
this  card  with  you 
when  you  come  to 
the  Dispensary, 
you  must  pay  ten 
cents  for  a  new 
card. 


Form  No.  3 


of  the  work  is  determined,  and  if  there  is  a  fee  for  an 
extraction  or  an  operation,  the  patient  should  not 
have  to  leave  the  chair  to  go  to  the  Admission  Desk, 
and  then  return,  wasting  the  dentist^s  time.  Similarly 
with  fees  for  eye  glasses.  Certain  specified  fees  may 
therefore  be  taken  in  a  clinic,  with  a  suitable  check 
provided  therein,  and  all  the  money  should  be  turned 
over  promptly  at  the  close  of  the  clinic  to  the  central 
office. 

The  most  interesting  section  of  the  Admission 
System  relates  to  the  new  patients.  The  interview 
with  the  person  applying  for  treatment  for  the  first 
time  determines  the  patient's  impression  of  the  Dis- 
pensary and  inspires  confidence  or  the  reverse.  From 
the  medical  standpoint,  correct  reference  of  the  patient 
to  the  proper  clinics  depends  considerably  upon  the 


200 


DISPENSARIES 


-  .  .  . .    'Olf  pensary 

Name 

Age                  yrs         mos.        INO. 

Addrfift 

8.  M.  W  D.                                      Came  to                  Parent 
Birthclflce                                           tJ    S   A                     NaliWtv 

Name  of  Parent 
Hnshand.  Wife 

nrrn  nf  Patient  (I».<i,r7..    n,„    r>r,^„A                                                       9- 

■Wlcly  Rale 

Oec'n  of  Head  of  Housthold 

I 

No. 

UtiemDlovmenl                                                                       Children  . 

No                             No 
Married                    Workinir            "       t 

.  .Others  deoendent.  contribulitiB 

PAlienI  cnmnlainsof 

-    Previou*  Ttealmrtl  (Prf«iJt»  dttkr,  ipur  Uttyvlai,  itct^im^fia). 

Reason  foi  Change 

Dept. 

Daie                                  Social  Service 

S.S.No 

1  V«» 
I  No 

_^ 

- 

V 

IMafnosis  Uifrn  vwi) 

_Bl»«npsi$  {jw  *..) 

- 

- 

Form  No.  4 


ADMISSION   SYSTEM 


201 


Patient's  Name 

Age           yrs. 

mos. 

No. 

Address 

Social  Status 

Birthplace 

Race  or  Color 

/ 

Name  of  Father,  Husband,  Etc. 

Remarks 

Dept. 

Date 

Dept, 

Date 

Dept. 

Date 

Dept 

Date 

Dept. 

Date 

Dept. 

Date 

Dept. 

Date 

Dept. 

Date 

DISPENSARY   REGISTRATION 

CARD 

Form  No.  5 

original  interview  at  the  Admission  Desk.  Adequate 
identifying  information*  and  facts  concerning  the 
social  condition  of  the  patient  are  also  of  importance 

*Identifying  Data:  Name  and  address  alone  are  not  adequate  as 
identifying  information.  Age  is  useful.  Of  especial  help  is  the  name 
of  a  parent  of  the  patient,  or  if  the  patient  is  of  middle  age  or  elderly, 
the  name  of  the  husband,  wife,  or  some  other  adult  member  of  the 
family,  will  be  sufl&cient,  with  the  name,  address,  and  age  of  .the  patient 
himself,  to  identify  him,  even  in  a  very  large  institution.  Many  similar 
names  are  found  and  securing  the  right  spelling  is  difBcult,  especially 
when  many  foreigners  are  included.  These  conditions  compHcate  the 
filing  of  the  index  cards  in  an  alphabetical  file,  and  as  the  alphabetical 
index  to  patients  is  of  the  greatest  importance,  a  system  of  securing  the 
necessary  information  must  be  devised.  With  certain  nationalities, 
Syrians  for  example,  patients  do  not  know  an  English  rendering  of  their 
name,  and  there  is  often  no  way  of  finding  out.  Other  difficulties 
present  themselves  with  such  names  as  Smith  or  Cohen,  which  are  often 
spelled  in  many  different  ways.  At  some  dispensaries,  the  expedient 
has  been  used  of  filing  certain  names  by  sound;  therefore  Cohen  and 
Kohn  would  be  filed  as  one,  the  patient  being  identified  by  the  first 
name  and  by  the  additional  discriminating  information  above  mentioned. 


202  DISPENSARIES 


DISPENSARY 


Patient*  t    Name- 


Signed- 


Form  No.  6 


Ezpires. 


DISPENSARY 


Patient's    Neune- 


Signed- 


Form  No.  7 


ADMISSION  SYSTEM  203 

from  both  medical  and  administrative  standpoints. 
The  first  essential  is  a  trained  and  competent  inquiry 
at  the  Admission  Desk. 

The  medical  placement  of  the  patient  in  the  proper 
clinic  depends  chiefly  on  eliciting  at  the  Admission 
Desk  a  correct  statement  of  symptoms.  Whether  or 
not  the  admitting  officer  is  a  physician,  physical 
examination  of  the  patient  is  not  possible  to  any 
large  extent  in  connection  with  the  Admission  Desk. 
In  some  institutions,  examining  rooms  or  booths  are 
provided,  but  the  number  of  cases  in  which  an  exam- 
ination is  actually  made  never  exceeds  a  small  per- 
centage of  the  total.  Many  institutions  find  it 
simpler  to  send  these  cases  to  the  Medical  or  the 
Children's  Clinic,  with  a  request  that  the  clinic  make 
an  examination,  and  then  refer  the  case,  no  clinical 
record  being  opened  until  the  question  of  location  is 
determined.  The  chief  difficulty  in  having  a  physi- 
cian at  the  Admission  Desk  is  that  the  young  physician, 
usually  an  interne,  has  had  no  special  training  in 
dealing  with  people.  He  is  not  usually  assigned  to 
the  admission  work  permanently,  and  does  not  look 
forward  to  acquiring  skill  in  such  a  service.  A  well 
educated,  permanent,  lay  admitting  officer,  under 
medical  supervision,  may  be  specially  trained  for  the 
task,  and  will  frequently  be  found  to  do  better  than 
the  physician  who  can  be  secured  for  such  work. 
Where  a  physician  with  the  needed  personal  qualifica- 
tions can  be  permanently  assigned  to  the  task  of  the 
Admitting  Desk  and  sufficiently  paid,  that  is  another 
question.     One  admitting  officer  cannot  pass  more 


204  DISPENSARIES 

than  fifteen  new  patients  per  hour  and  do  proper 
work.  Hence  in  a  large  Dispensary  more  than  one 
admission  desk  is  desirable.  It  is  well  when  there  are 
two,  that  one  be  a  man  and  one  a  woman.  Waiting 
benches  should  be  provided  sufficient  to  seat  the  maxi- 
mum number  of  new  patients  that  will  be  found  at 
any  one  time.  Old  patients  pass  quickly  to  the 
Cashier's  desk  and  have  to  wait  but  a  very  short 
period.  Many  waiting  benches  are  not  therefore 
necessary  for  them,  but  a  certain  amount  of  seating 
space  should  be  provided  for  the  few  that  have  to 
wait  long  for  one  reason  or  another,  or  for  those  that 
ought  not  to  stand  at  all  because  they  are  lame, 
feeble  or  carrying  babies. 

The  exclusion  of  patients  having  contagious  disease 
must  be  provided  for  in  the  admission  system.  Where 
there  are  many  children  among  the  patients,  this  is  of 
the  greatest  importance.  Certain  Dispensaries  have 
adopted  the  excellent  system  of  having  all  children 
diverted  from  the  main  stream  of  incoming  traffic, 
and  pass  by  a  physician,  who  looks  at  each  child's 
throat,  eyes,  and  the  skin  of  the  face  and  neck.  Sus- 
picious cases  are  put  aside  for  careful  examination. 
Sometimes  as  high  as  two  per  cent  of  all  the  children 
entering  the  doors  have  been  taken  out  in  this  way; 
although  this  proportion  is  probably  much  higher  than 
average.  In  most  Dispensaries,  the  children  pass  to 
the  general  admission  desks  along  with  the  adults, 
and  the  admitting  officers  are  responsible  for  picking 
out  cases  of  probable  or  possible  contagious  disease. 
A  trained  lay  officer  becomes  after  a  time  as  expert  as 


ADMISSION  SYSTEM  205 

the  average  interne  in  ''spotting''  the  cases  and  put- 
ting them  aside  for  examination  by  a  pediatrician. 
Under  any  circumstances  there  must  be  an  isolation 
room  or  booth,  near  the  admission  desks,  in  which 
such  children  can  be  detained  until  a  positive  or 
negative  diagnosis  is  made.  The  child  is  then  either 
admitted  to  the  Dispensary,  or  else  sent  home  or  to  a 
hospital  for  contagious  diseases. 

The  questions  to  be  asked  of  the  new  patient  at  the 
Admission  Desk  and  the  record  that  should  be  made 
are  indicated  on  the  ''clinic  record"  (No.  4)  of  the 
preceding  set  of  forms.  Information  gathered  at  the 
Admission  Desk  concerning  the  patient's  social  con- 
dition may  be  useful  to  the  Social  Service  Department, 
and  may,  at  the  discretion  of  the  admitting  officer,  be 
transmitted  to  the  proper  social  worker.  This  social 
information,  while  often  thought  of  as  merely  for  the 
purpose  of  determining  the  patient's  admission  or 
exclusion,  can  and  ought  to  be  used  for  many  con- 
structive purposes.  The  previous  medical  treatment 
which  the  patient  has  received  should  always  be  asked 
for.  Treatment  simultaneously  or  recently  received 
at  another  Dispensary  in  the  same  city  is  good  reason 
for  rejecting  the  patient,  unless  some  unusual  cir- 
cumstance is  manifest.  Treatment  by  a  private 
physician  should  lead  to  the  reference  of  the  patient 
back  to  that  physician,  unless  good  reason  appears  to 
the  contrary.  Of  course  many  patients  are  referred 
to  a  Dispensary  by  private  physicians  for  special 
treatment,  for  consultation,  or  because  the  patient 
has  no  more  money.    Unless  the  Dispensaries  of  a 


206  DISPENSARIES 

city  have  by  mutual  arrangement  districted  the  area, 
previous  treatment  at  another  Dispensary  for  some 
disease  other  than  the  one  for  which  the  patient  now 
applies  should  not  of  itself  be  ground  for  rejection. 

The  admitting  officer  should  be  able  to  talk  with 
j  each  new  patient  in  a  position  which  gives  a  sense  of 
privacy.  A  screen  partly  around  the  admission  desk 
will  accomplish  this  and  is  more  expeditious  than  a 
separate  room. 

The  late  comers,  reason  for  whose  tardiness  must  be 
satisfactory  to  the  admitting  officer,  present  a  some- 
what vexatious  problem.  The  remission  of  fees  is  a 
problem  in  itself  and  should,  so  far  as  possible,  be 
made  the  responsibility  of  the  admission  desk.  Trans- 
fers or  re-admissions  are  still  another  important  duty 
of  the  admitting  officers.  Under  no  circumstances 
should  a  patient  who  has  received  treatment  in  one 
clinic  be  allowed  to  go  to  another  clinic  merely  because 
of  his  own  request.  The  general  rule  should  be  that 
such  transfers  should  be  made  on  the  direction  of  the 
physician  of  the  clinic  that  has  already  treated  the 
patient.* 

The  staff  required  for  an  admitting  system  may  be 
briefly  outlined. 

*  Certain  exceptions  are  convenient,  e.g.,  a  patient  who  had  been 
treated  in  1915  in  an  Eye  CHnic  and  comes  in  1917  with  a  cut  finger, 
might  be  sent  by  the  admitting  officer  directly  to  the  Surgical  Depart- 
ment. A  patient  might  have  a  tooth  pulled  in  the  Dental  Department 
on  Monday,  and  apply  for  admission  to  the  Eye  Department  a  week 
later.  Thus,  the  general  rule  should  be:  transfer  only  by  physician; 
but  certain  specified  exceptions  can  be  formulated  and  their  application 
left  to  the  discretion  of  the  admitting  officer. 


ADMISSION  SYSTEM  207 

Most  essential  is  a  competent  head.  The  head  of 
the  admission  department  may  well  be  designated 
Registrar.  For  a  Dispensary  receiving  an  average  of 
three  hundred  visits  per  day,  of  which  about  one-third 
would  be  reportable  by  the  New  Patients'  Desk  (new 
persons  and  re-admissions),  the  following  persons  in 
the  admission  department  would  be  necessary : — 

1.  Registrar:  taking  general  charge  of  admissions  and 
herself  (or  himself)  doing  duty  at  one  of  the  two  admission 
desks  for  new  patients. 

2.  Assistant  Registrar:  doing  duty  at  the  other  admission 
desk  for  new  patients.  The  assistant  could  devote  his  or 
her  time  after  admitting  hours  to  other  duties. 

3.  Head  record  clerk:  on  duty  in  the  central  record  room, 
taking  out  records  during  cHnic  periods  and  filing,  etc., 
thereafter. 

4.  Assistant  record  clerk. 

5.  Index  and  lost  card  clerk.  A  special  person  is  neces- 
sary at  the  lost  card  desk  during  the  admission  period  and 
the  same  person  might  well  have  charge  of  typewriting  the 
index  cards  (which  ought  to  be  typewritten  and  not  hand- 
written), and  of  the  alphabetical  index  under  the  direction 
of  the  head  record  clerk. 

6.  Cashier:  responsible  for  receiving  money  during  the 
cHnic  period  and  afterward  assisting  in  the  record  room  or 
elsewhere. 

7.  Page :  taking  records  during  the  clinic  period  through-  f 
out  the  Dispensary.     This  may  be  a  boy  or  young  man  who  j 
can  assist  in  other  work  in  the  hospital  or  Dispensary  after/ 
the  admission  period  is  over.     Where  there  is  not  an  ample! 
supply  of  orderlies,  two  pages  would  be  more  desirable. 

8.  Usher:  Man  or  girl  near  the  front  door,  dividing  old 
from  new  patients.     This  person  may  perform  other  duties, 


208  DISPENSARIES 

such  as  that  of  information  clerk,  telephone  operator,  etc. 
The  arrangement  of  the  hall  may  possibly  render  a  special 
usher  unnecessary. 

For  each  additional  one  hundred  average  visits  per 
day,  it  will  be  necessary  to  add  an  additional  record 
clerk  during  the  clinic  period  to  take  out  records 
promptly  when  pressure  comes.  For  each  additional 
twenty-five  new  cases  (new  persons  and  re-admissions) 
per  day  it  will  be  necessary  to  add  an  additional  desk 
or  lengthen  the  period.  The  number  of  pages  will 
depend  on  the  arrangement  of  the  building  and  the 
mechanical  devices  which  may  be  introduced  for 
carrying  records. 

An  important  section  of  the  duty  of  the  Registrar 
is  to  provide  and  take  charge  of  the  statistics  of  at- 
tendance. All  statistics  should  be  under  her  charge, 
whether  prepared  by  the  workers  in  her  own  division 
or  by  persons  in  the  clinics.  The  technique  of  keep- 
ing statistics  and  reporting  thereon  is  discussed  in 
Chapter  XIII. 

A  further  and  useful  function  of  a  well-organized 
admitting  system  is  answering  inquiries  concerning 
patients,  whether  received  from  patients  themselves, 
their  friends,  or  in  relation  to  court  cases.  These 
inquiries  come  partly  by  mail  and  partly  by  personal 
inquiry  and  by  telephone.  While  the  Dispensary  is 
often  under  no  legal  obligation  to  furnish  records  or 
information,  and  for  the  sake  of  the  patient  must 
sometimes  withhold  it,  it  is  the  duty  of  the  institution 
to  co-operate  in  any  manner  that  may  benefit  the 
patient  or  may  avoid  injustice  to  some  interested 


ADMISSION  SYSTEM  209 

party.  The  Registrar  or  an  assistant  may  be  desig- 
nated by  the  superintendent  to  look  up  records,  and 
either  be  given  the  power  to  answer  inquiries  in  cer- 
tain specified  cases,  or  to  report  the  facts  to  the  super- 
intendent, or  other  designated  officer,  who  will  decide 
what  is  to  be  done. 

Taking  the  admission  system  as  a  whole,  it  will  be 
seen  that  a  considerable  body  of  useful  and  important 
functions, — medical,  administrative  and  social, — can 
be  collected,  as  it  were,  and  made  a  Department.  It 
is  useful  to  do  this  in  a  large  Dispensary  because  thus 
a  sufficient  body  of  duties  can  be  gathered  together 
to  warrant  the  employment  of  a  specially  trained  and 
competent  head.  Thoughtful  and  accurate  admitting, 
good  records,  useful  statistics,  and  helpful  relation- 
ships to  outside  institutions,  largely  depend  upon 
this  department  and  upon  the  person  in  charge  of  it. 


210  DISPENSARIES 


CHAPTER  XIII 
RECORDS  AND   STATISTICS 

Records  in  a  Dispensary  are  of  four  kinds: 

(1)  Case  Records  of  individual  patients,  medical,  social, 
and  administrative; 

(2)  Records  showing  bulk  of  work,  i.e..  Statistics; 

(3)  Records  analyzing  character  and  results  of  work,  i.e., 
Efficiency  Records;  and 

(4)  Administrative  Records  as  of  expenditures,  income, 
and  purchases  and  use  of  supplies.* 

I.  Case  Records 

These  may  again  be  divided  into  three  types;  first 
the  permanent  medical  record  of  individual  cases,  each 
containing  the  diagnosis  and  course  of  treatment  of  a 
patient  in  one  or  more  clinics;  second,  records  of  the 
Social  Service  Department,  containing  social  data, 
analyses  and  treatment;  third,  temporary  or  adminis- 
trative records  which  are  used  to  facilitate  the  various 
procedures  of  transfer,  inquiry,  etc.,  conducted  from 
the  different  clinics,  the  laboratories,  etc. 

There  has  been  much  detailed  discussion  of  the  most 
desirable  form  for  medical  records.  Formerly  Dis- 
pensary records  were  usually  kept  in  books;  each 
patient  had  a  line.     This  was,  of  course,  before  there 

*  Type  (3)  is  treated  in  the  chapter  on  Efficiency  Tests;  type  (4)  in  the 
chapter  on  Finance. 


RECORDS  AND   STATISTICS  211 

was  any  idea  of  continuous  supervision  of  treatment 
or  of  doing  more,  in  most  cases,  than  to  relieve  symp- 
toms by  giving  a  prescription.  As  the  standard  of 
Dispensary  work  advanced,  especially  in  teaching 
institutions,  spaces  with  several  lines  were  often  ruled 
off  on  the  pages  of  the  book.  Thus  not  only  name, 
address  and  prescription,  but  diagnosis  and  treatment 
could  be  entered.  But  the  only  satisfactory  and  now 
almost  the  universal  method  in  Dispensaries  of  stand- 
ing, is  the  card  record. 

The  tendency  has  been  towards  the  adoption  of  a     I 
form  of  card  approximately  6  inches  wide  and  9  inches     y 
high.     A  very  wide  card  is  not  so  convenient  to  write 
on  as  a  narrower  one.     Too  large  a  card  is  incon- 
venient and  one  too  small  is  wasteful  of  time  and 
stationery.     (See  sample  form,  page  200.) 

Some  teaching  Dispensaries  of  high  rank  use  a  paper 
folder,  giving  four  pages,  and  thus  ample  space  for  j 
detailed  entries;  the  paper,  when  not  in  use,  being  [ 
protected  by  an  envelope  or  a  heavy  folder.  But  for 
the  average  Dispensary  the  card  is  better.  Even  in 
the  teaching  Dispensary,  the  proportion  of  cases  re- 
quiring very  full  records  is  not  large,  so  that  the  in- 
convenience of  several  cards  needed  for  a  relatively 
few  cases  may  well  be  overbalanced  by  the  greater 
convenience  of  the  card  system  for  the  average  case. 

A  multitude  of  different  forms,  each  used  in  one  or 
more  representative  Dispensaries,  might  be  described. 
We  shall,  however,  confine  this  discussion  to  certain 
principles.  With  the  increased  requirements  for  thor- 
ough medical  work  in  Dispensaries,  there  was  for  a 


212  DISPENSARIES 

time  a  tendency  toward  very  detailed  printed  forms. 
All  the  items  which  might  be  recorded  in  a  complete 
physical  examination  would  be  printed  on  the  cards 
with  spaces  left  for  writing  in  or  checking. 

But  with  longer  experience  both  in  medical  teaching 
and  in  management  of  clinics,  the  detailed  record  form 
has  been  largely  abandoned  and  now  usually  only  a  few 
printed  headings  are  found.     The  printed  headings,  if 

'  in  great  detail,  do  not  admit  of  adapting  space  to 
varied  cases,  one  of  which  will  require  much  writing 
under  item  A  and  little  under  item  B,  while  another 
case  may  need  just  the  reverse.  To  a  considerable 
extent  the  printed  headings  may  be  replaced  by  the 

I  use  of  rubber  stamps,  with  much  gain  in  time  and 
space.  Each  stamp  contains  an  item  or  a  set  of  items, 
with  space  after  each  for  filling  in  or  checking  the 
findings.  Special  examinations  which  are  not  per- 
formed on  every  case  can  each  have  their  rubber  stamp 
in  the  clinics  needing  them.  Diagrams  of  the  chest, 
teeth,  etc.,  if  on  rubber  stamps,  can  be  impressed  on 
the  particular  part  of  the  record  card  where  they  are 
most    convenient.     So   with   stamps   for   laboratory 

\  reports,  etc.  This  rubber  stamp  plan  can  be  devel- 
oped quite  extensively  and  renders  the  use  of  a  moder- 
,  ate-sized  card  with  a  few  printed  items  on  it,  adaptable 
to  many  different  clinics  or  purposes.  The  medical 
student  also  is  placed  more  on  his  own  responsibility 
by  a  card  with  a  few  items  than  with  one  that  has  each 
heading  for  the  examination  printed  before  his  eyes. 

The  social  or  identifying  items  can  be  reduced  to 
much  greater  uniformity  than  the  medical,  and  the 


RECORDS  AND  STATISTICS  213 

problem  is  therefore  simpler.  They  can  well  be  printed 
on  the  record  card,  or,  as  in  some  Dispensaries,  on  a 
special  card.  Where  the  card  records  for  each  pa- 
tient are  filed  in  a  folder  or  envelope,  the  social  items 
have  sometimes  been  printed  on  the  outside  of  this 
cover.  As  indicated  in  Chapter  XII,  it  is  desirable 
that  the  identifying  information  concerning  the  pa- 
tient, the  identifying  number,  and  certain  social  items, 
be  taken  and  recorded  at  the  central  admission  desk 
rather  than  in  the  clinics. 

In  a  large  Dispensary,  the  great  number  of  records 
raises  at  once  the  problem  of  filing  and  distribution. 
In  the  old  type  of  Dispensary  each  doctor  looked  up 
his  own  set  of  records,  or  each  clinic  had  its  set;  there 
was  no  uniform  system  of  filing  and  no  way  of  telling 
in  how  many  different  clinics  a  patient  was  receiving 
treatment.  The  Massachusetts  General  Hospital  was 
a  pioneer  in  establishing  a  central  record  room  in  ] 
which  all  the  clinical  records  are  kept  and  from  which 
they  are  distributed  daily  as  the  patients  come  in.  ' 
From  the  standpoint  of  the  specialist  who  is  simply 
interested  in  seeing  what  particular  cases  in  his  own 
line  are  being  treated  and  what  treatment  is  followed, 
there  are  certain  advantages  in  having  all  the  records 
of  his  own  specialty  filed  in  his  own  clinic  in  chronologi- 
cal order.  But  from  the  standpoint  of  an  institution 
as  a  whole,  for  the  best  play  of  co-operative  diagnosis, 
and  for  the  utmost  benefit  to  the  patient,  an  assembling 
in  one  group  of  all  the  medical  information  concerning 
each  patient,  is  undoubtedly  essential. 

The  advantages  of  a  central  record  room  are  partly 


214  DISPENSARIES 

administrative;  they  make  a  single  person  or  group  of 
persons  responsible  for  filing  records  and  for  keeping 
them  in  good  condition.  A  higher  value  is  the  pos- 
sibility of  centralizing  all  the  medical  information 
pertaining  to  each  patient.  The  patient  is  the  unit  of 
treatment,  not  the  clinic.  If  the  patient  needs  ex- 
amination and  treatment  in  two  clinics,  all  the  records 
made  in  each  clinic  (usually  each  on  a  separate  card) 
are  put  together  in  a  folder  or  by  some  binding  device, 
and  filed  in  the  central  room.  When  sent  to  any  clinic 
at  the  next  visit  of  this  patient,  they  are  sent  together. 
Thus  the  physician  in  each  clinic  has  opportunity  to  see 
the  diagnosis  and  treatment  of  every  other  depart- 
ment. Attempts  have  been  made  in  some  institutions 
to  use  a  single  record  card,  instead  of  a  separate  card 
for  each  clinic.  At  each  visit  of  a  patient  the  clinic  to 
which  he  goes  writes  the  record  of  treatment  on  the 
next  blank  space  on  the  card.  So  many  practical 
disadvantages  seem  attached  to  this  plan  that  it  can- 
not be  recommended. 

It  must  be  borne  in  mind  that  there  are  three  re- 
lationships between  clinics,  with  respect  to  the  joint 
examination  or  treatment  of  a  patient : 

(1)  Consultation,  i.e.,  Doctor  in  Clinic  A  takes  patient 
personally  to  Doctor  in  Clinic  B,  or  sends  for  Doctor  in 
Clinic  B  to  come  to  see  the  patient  in  Clinic  A.  The  two 
doctors  talk  over  the  case,  and  a  record  of  Doctor  B's  opin- 
ion is  made  directly  on  the  card  in  Clinic  A. 

(2)  Refer,  i.e.,  the  patient  is  sent  with  a  ''Refer"  slip 
from  Clinic  A  to  Clinic  B.  This  is  the  same  as  Consultation, 
except  that  the  doctors  do  not  meet  personally.     In  this 


RECORDS   AND   STATISTICS  215 

case,  the  record  card  from  Clinic  A  is  sent  via  the  central 
record  room  to  Clinic  B,  and  the  doctor  enters  his  opinion 
thereon.  The  patient  may  be  treated  thereafter  in  both 
clinics,  and  if  he  is  treated  in  B,  a  new  clinic  card  is  opened. 
(3)  Transfer,  i.e..  Doctor  in  Clinic  A  thinks  the  patient 
needs  treatment  in  Clinic  B  instead  of  in  A.  The  patient 
goes  to  Clinic  B  with  a  "Transfer"  SHp.  The  record  from 
Clinic  A  goes  to  B  also,  and  if  B  accepts  the  patient  for 
treatment,  B  opens  a  new  card  for  the  patient  in  that  clinic. 
The  patient  then  ceases  to  go  to  A.  A's  card  will  contain 
a  final  entry:  ''Date:  Transferred  to  Clinic  B." 

It  is  possible  to  maintain  a  fairly  adequate  system  of 
correlating  clinics  without  a  central  filing  system,  pro- 
vided the  following  principles  are  adhered  to:  (1) 
Each  patient  must  be  given  a  single  identifying  num- 
ber which  his  record  in  every  clinic  contains.  The 
clinic  records  are  filed  according  to  this  number  in  each 
clinic.  (2)  The  patient  is  given  an  admission  card  on 
which  is  stamped  his  number  and  also  the  name  of 
every  clinic  to  which  he  is  sent.  If  he  begins  in  the 
Medical  Clinic,  and  later  must  be  transferred  to  the 
Orthopedic,  the  name  of  the  latter  clinic  must  be 
stamped  on  his  admission  card  (at  the  Cashier's  desk) 
at  the  time  of  the  transfer.  The  physician  by  looking 
at  this  admission  card  each  time  the  patient  comes  in 
can  see  what  clinics  the  patient  has  been  in  and  can 
send  for  the  records,  if  he  desires  information  from  the 
physicians  of  the  other  departments.  (3)  There  must 
be  an  index  card  made  at  the  first  visit,  with  the  num- 
ber and  identifying  data  concerning  the  patient  and 
the  name  of  the  clinic  to  which  he  is  sent.  If  he  goes 
afterward  to  other  clinics,  their  names  are  also  stamped 

15 


216  DISPENSARIES 

on  the  index  card.  The  index  cards  are  filed  in  a 
central  alphabetical  file;  they  furnish  an  index  to  all  the 
records  in  the  Dispensary,  although  it  may  be  neces- 
sary to  hunt  in  several  different  clinics  to  assemble  all 
the  records  about  any  one  patient. 

It  may  be  pointed  out  that  the  three  preceding 
principles  all  apply  to  the  central  record  system  also, 
and  these  three  principles  are  in  fact  the  basis  of  any 
good  plan  of  Dispensary  records.  With  a  central 
record  room,  all  the  records  of  each  patient  are  kept 
together.  The  alphabetical  index  furnishes  adminis- 
trative control.  Entering  the  list  of  all  the  patient's 
clinics  on  his  admission  card  is  no  longer  necessary, 
though  at  times  it  is  a  convenience. 

The  details  of  management  of  the  record  room  and 
the  staff  required  have  been  already  treated  in  the 
preceding  chapter. 

The  records  of  the  Social  Service  Department  may 
be  regarded  as  those  of  a  special  clinic.  ^'Social 
Service ''  should  be  entered  on  the  index  and  admission 
card,  as  if  the  patient  went  to  a  dental  or  surgical 
clinic.  The  frequency  with  which  social  records  on 
active  cases  must  be  consulted  is  one  reason  why  the 
social  case  records  have  usually  been  filed  separately 
from  the  medical  records.  In  most  instances  they  are 
filed  in  a  separate  number  series.  In  many  social 
cases  the  records  involve  descriptive  details,  copies 
of  correspondence,  etc.,  and  are  bulky,  and  it  has  not 
been  thought  desirable  to  burden  the  clinic  doctors  by 
having  these  social  records  accompany  the  medical 
records  to  the  clinic. 


RECORDS   AND   STATISTICS  217 

The  record  forms  which  have  been  found  useful  in 
Social  Service  Departments  are  fully  treated  in  Miss 
Cannon's  book. 

The  third  type  of  case  records  are  for  temporary 
administrative  service  only,  instead  of  being  perma- 
nent records.  The  chief  forms  may  be  listed  as 
follows : 

(1)  The  Refer,  already  defined.  Where  there  is  a 
central  record  system,  the  record  card  of  the  referring 
clinic  automatically  comes  back  at  the  patient's  next 
visit,  thus  furnishing  the  doctor  with  the  report  de- 
sired. Where  there  is  not  a  central  system,  the 
Refer  must  contain  a  stub  on  which  the  report  must  be 
written. 

(2)  Transfer.  The  Refer  and  Transfer  Slips  are 
often  combined,  by  having  a  bracketed  heading  like 
the  following,  the  physician  checking  the  one  desired. 

J  Referred  for  Diagnosis  and  Report \  Ph    V 

\  Transferred  for  Diagnosis  and  Treatment .  .  / 

Where  there  is  no  central  record  system,  a  Refer- 
Transfer  blank  in  the  following  form  (No.  8)  has  been 
found  useful.  The  small  stub  is  kept  in  the  original 
clinic  until  the  report  returns,  furnishing  a  check. 
The  missing  reports  can  be  periodically  hunted  out. 
With  a  central  record  system  the  stub  can  also  be 
used,  but  will  usually  be  unnecessary. 

(3)  X-ray  Refer.  A  useful  form  is  printed  here- 
with (No.  9). 

(4)  Laboratory  Refer.  This  must  be  adaptable  to 
various  types  of  specimens,  such  as  blood-counts, 
urines,  stomach  contents,  Wassermanns,  etc.     Several 


218 


DISPENSARIES 


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RECORDS  AND  STATISTICS 


219 


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220  DISPENSARIES 

different  forms,  or  a  single  form  with  appropriate 
headings  and  spaces,  may  be  used.  The  single  form 
is  preferable.  Since  the  Laboratory  must  render  a 
report,  the  type  of  form  just  described  for  the  Trans- 
fer is  the  best.  Gummed  slips  for  the  Laboratory  re- 
port form  have  been  used,  to  be  pasted  on  the  clinic 
record  card,  saving  copying.  But  they  are  likely  to  be 
inconvenient  and  a  better  plan  is  the  use  of  a  rubber 
stamp,  which  minimizes  writing  and  time. 
1  (5)  Hospital  Refer.  In  a  Dispensary  which  is  the 
Out-Patient  Department  of  a  hospital,  sending  the 
patient  into  the  wards  requires  merely  the  usual 
*^ Refer"  blank,  although  more  elaborate  forms, 
including  medical  and  social  data  concerning  the 
patient,  are  in  use.  When  a  Dispensary  is  not  con- 
nected with  a  hospital,  or  for  any  reason  must  send  a 
patient  to  a  hospital  outside,  a  different  form  should 
be  used.  The  example  printed  will  indicate  the  points 
covered,  viz.,  definiteness  of  reference;  provision  of 
information  wanted  by  the  hospital  admitting  officer; 
provision  for  report,  so  that  the  Dispensary  learns 
whether  the  patient  actually  reached  the  hospital  and 
was  admitted.  The  return  slip,  when  sent  back  by 
the  hospital,  covers  this  need. 

Considerable  attention  has  been  recently  devoted 
to  the  proper  relation  of  the  Dispensary  records  to 
those  of  the  hospital  of  which  the  Dispensary  is  a  part. 
There  should  be  a  complete  interchange  of  information 
between  the  two  branches  of  the  institution.  The  pa- 
tient, not  the  department,  should  be  the  unit.  When 
the  patient  goes  to  the  hospital  ward,  the  Dispensary 


RECORDS  AND   STATISTICS 


221 


2000-lMS 


— ^ Dispensary 


(Date) 


To  Admitting  PHvsiaAN: 
This  patient 


(Name) 

Addresa = ;.. , 

(Stpect.  Number  and  Town) 

is  recommended  for  admission  to  Hospital  from 


No 

Diagnosis 


.191 


Department  of  Dispensary. 


M.  D. 


Superintendent 


ITo 


Name...,. 
Address 


DETACH  THIS  SLIP.  FIl,!,  OUT  AND  RETURN 

Superintendent  of  Dispensary 


No : 

Admission  Diagnosis _^-_ 

Has  been  admitted  to  Ward _ „ Service 

to-day      Date ! ^ ^..191 


Form  No.  10 


222  DISPENSARIES 

record  should  follow  him  so  that  all  desired  information 
can  be  noted  by  the  interne  and  the  attending  physi- 
cian. In  some  cases  the  information  wanted  is 
copied  out  on  the  ward  record.  In  a  few  institutions, 
the  hospital  record  and  the  Dispensary  record  of  the 
same  case  are  filed  together.  This  has  many  practical 
disadvantages.  The  number  of  Dispensary  cases 
usually  is  much  larger  than  the  ward  cases.  Many 
hospital  cases  never  enter  the  Dispensary,  and  vice 
versa.  The  forms  and  sizes  of  cards  convenient  for 
hospital  records  are  not  on  the  whole  those  which  have 
been  found  most  advantageous  for  a  Dispensary. 
Special  conditions  in  a  particular  institution  may  per- 
haps render  desirable  the  joint  filing  of  hospital  and 
Dispensary  records;  but  as  a  rule  they  had  best  be 
separate.  Of  course  the  alphabetical  index  to  pa- 
tients could  be  for  the  institution  as  a  whole,  and 
should  indicate  all  the  clinics  as  well  as  the  hospital 
(or  the  wards)  in  which  the  patient  has  been  cared  for 
at  any  time.  The  separate  filing  of  ward  and  Dis- 
pensary records  is  not  inconsistent  with  having  a 
single  record  room  for  both  branches  of  the  work. 

As  a  general  policy  for  relating  the  hospital  and 
out-patient  department  records  the  following  may  be 
outlined : — 

When  a  patient  passes  from  the  out-patient  department 
to  a  ward,  the  dispensary  records  should  be  sent  to  the 
latter  and  examined  by  the  interne  and,  if  necessary,  by 
the  attending  physician.  Notes  are  put  upon  the  hospital 
record,  after  which  the  dispensary  record  is  returned  to  its 
file.     On  the  discharge  of  any  patient  from  the  hospital  to 


RECORDS  AND   STATISTICS  223 

the  out-patient  department,  the  hospital  record  should  be 
sent  to  the  appropriate  out-patient  clinic,  and  should  be 
examined  there  by  the  man  who  has  charge  of  the  patient. 
He  in  turn  may  make  such  notes  as  desired  on  the  Dispen- 
sary record  and  then  the  hospital  copy  should  be  returned 
to  its  own  file.  Some  institutions  have  an  Out-Patient 
Summary,  usually  very  brief,  sent  with  the  patient  from  the 
Dispensary  to  the  ward,  and  a  Ward  Summary  sent  in  the 
reverse  direction;  instead  of  sending  the  full  record.  The 
latter  plan  is  to  be  preferred. 

In  administering  a  Dispensary  record  system  there 
should  be  kept  in  mind  a  cardinal  point  mentioned  in 
preceding  chapters,  viz.,  a  responsible,  trained  person 
in  charge  of  the  records.  The  Registrar  may  be  this 
person,  although  the  record  system  of  an  out-patient 
department  may  be  so  unified  with  that  of  the  hospital 
that  the  librarian  of  the  latter  will  have  supervision  of 
the  dispensary  records  also.  Since  the  Registrar  will 
devote  a  considerable  portion  of  time  to  the  admis- 
sion of  patients,  there  must  be  a  first  lieutenant  in  the 
record  room  itself,  i.e.,  a  chief  clerk.  This  is  a  not 
unimportant  position  in  a  large  Dispensary,  calling  for 
quick,  accurate  and  conscientious  executive  work. 

A  record  system  in  a  Dispensary  does  not  reach  its 
maximum  of  mechanical  perfection  or  of  medical 
usefulness  unless  there  is  skilled  supervision  of  the 
content  of  the  records.  No  record  should  be  filed  until 
it  has  been  examined  for  the  accurate  entry  of  the 
identifying  data.  This  can  be  done  by  one  or  more  of 
the  record  and  file  clerks.  Beyond  this,  there  ought 
to  be  periodical  examinations  of  the  records  in  each 


224  DISPENSARIES 

clinic  by  a  physician,  who  will  criticise  the  medical 
content.  Ideally  this  should  be  done  by  the  chief 
physician,  but  when  this  is  impossible,  another  person 
should  do  the  reading  and  call  to  the  attention  of  the 
head  of  the  clinic  each  instance  of  certain  defects, 
designated  in  advance.  The  proper  filling  out  of  a 
definite  diagnosis,  the  entry  of  the  essential  details  of 
physical  examinations,  and  the  recording  of  treatment 
or  condition  at  each  visit,  should  be  especially  looked 

for. 

2.  Dispensary  Statistics 

What  is  the  essential  unit  for  measuring  Dispensary 
work?  In  Out-Patient  Department  reports  there 
usually  appear  such  terms  as  ''New  Patients"  and 
''Old  Patients."  These  are  ambiguous.  "New  Pa- 
tients" may  mean  persons  who  have  come  to  the 
Dispensary  for  the  first  time  in  their  lives  during  the 
current  year,  or  again  it  may  mean  persons  who  have 
come  to  a  particular  clinic  for  the  first  time.  In 
Dispensaries  where  each  clinic  keeps  its  own  statistics, 
if  a  patient  has  gone  during  a  year  to  three  clinics  for 
the  first  time,  he  will  be  recorded  three  times  as  a  new 
patient. 

"Old  Patients"  may  mean  persons  who  are  going 
to  the  same  clinic  a  second  time,  or  those  who  are  going 
to  a  new  clinic.  The  confusion  exists  chiefly  because 
there  are  two  factors  to  be  kept  in  mind:  first,  the 
Dispensary  as  a  whole;  second,  each  clinic  as  a  depart- 
ment. There  are  really  five  items  we  ought  to  know, 
as  the  basal  data  for  measuring  the  bulk  of  a  Dispen- 
sary's work  during  any  specified  period. 


RECORDS   AND   STATISTICS  225 

(1)  New  Persons:  The  number  of  different  in- 
dividuals admitted  as  patients  for  the  first  time  to  the 
Dispensary  as  a  whole. 

(2)  New  Clinic  Patients:  The  number  of  different 
individuals  admitted  for  the  first  time  to  each  clinic. 

(3)  Total  Persons:  The  number  of  different  in- 
dividuals treated  in  the  Dispensary  as  a  whole  during 
the  period  covered. 

(4)  Total  Clinic  Patients:  The  number  of  different 
individuals  treated  in  each  clinic  during  the  period. 

It  will  be  noted  that  the  sum  of  the  '^New  Clinic 
Patients"  (2)  for  all  clinics  will  not  be  the  same  as 
''New  Persons"  (1)  in  the  Dispensary.  Likewise  the 
''Total  Clinic  Patients"  (4)  summed  together  for  all 
clinics,  is  much  larger  than  the  "Total  Persons"  (3) 
for  the  Dispensary  as  a  whole,  during  the  same  period. 
There  is  one  figure,  however,  which  is  not  ambiguous, 
and  that  is 

(5)  Total  visits,  i.e.,  the  number  of  treatments  given 
patients.  These  are  properly  recorded  by  clinics,  for 
the  clinic  is  the  unit  in  which  treatment  is  given; 
but  the  sum  of  all  visits  to  clinics  gives  the  total  of 
treatments  in  the  Dispensary  as  a  whole.  This  is  the 
fundamental  unit  of  dispensary  work. 

Even  in  a  poorly  organized  Dispensary,  "Total 
Visits"  can  be  easily  and  accurately  kept.  The  total 
of  attendance  at  each  clinic,  each  session,  added  all 
together,  gives  the  figure  for  the  institution. 

"New  Persons"  is  not  difficult  to  keep  if  there  is  a 
good  central  admitting  system,  with  adequate  identify- 
ing information  recorded  and  an  alphabetical  index. 


226  DISPENSARIES 

This  item  is  chiefly  of  interest  as  an  indication  of  the 
spread  of  the  Dispensary's  work  each  year.  Where  a 
serial  number  is  issued  to  each  new  person,  the  dif- 
ference between  the  first  and  last  number  issued  during 
any  period  gives  the  number  of  new  persons. 

^'New  Clinic  Patients"  is  also  easy  to  secure,  for  a 
patient  automatically  makes  a  record  at  the  time  of 
first  admission  to  any  clinic,  whether  by  transfer  or 
from  the  admission  desk.  In  the  admission  system 
described  (Chapter  XII),  the  cashier's  clinic  slip  stubs 
(see  page  196)  give  the  total  visits;  while  the  admission 
desk  index  cards  give  the  new  clinic  patients. 

^^ Total  Persons"  and  ^^ Total  Clinic  Patients"  are 
interesting  items  but  troublesome  to  obtain.  They 
require  that  a  special  entry  be  made  the  first  time  (dur- 
ing each  year)  that  a  patient  enters  a  clinic  or  the 
Dispensary  as  a  whole.  Individuals  must  be  discrim- 
inated as  such  and  the  same  person  entered  only  once 
each  year.  One  method  of  doing  this  is  to  put  upon 
the  patient's  record  card,  when  it  passes  out  of  the  cen- 
tral record  room  to  a  clinic,  a  small  '' signal"  (the  col- 
ored steel  '* signals"  are  best).  Such  a  signal  is  also 
put  on  a  new  record  card,  when  made  out  for  a  new 
person.  The  number  of  signals  used  on  any  day  is 
the  number  of  different  individuals  (or  '^  Total  Per- 
sons") treated  on  that  day,  and  so  on  for  a  month  or 
year.  If  the  signals  are  colored  according  to  clinics, 
the  number  of  each  color  used  will  give  the  '^  Total 
Clinic  Patients"  in  each  clinic.  Even  this  plan  in- 
volves much  labor,  more  than  may  be  justified  by  the 
value  of  the  information  secured. 


RECORDS  AND  STATISTICS  227 

In  practice^  Dispensaries  should  secure  and  record  at 
least : — 

1.  Total  Visits. 

2.  New  Persons, 

3.  New  Clinic  Patients. 

Methods  of  recording  and  utilizing  this  information 
are  treated  later  in  this^chapter  and  in  the  chapter  on 
Efficiency  Tests. 

The  ordinary  work  of  the  admission  desk  renders  it 
easy  to  secure  certain  other  statistics  of  much  interest. 
Patients  may  be  classified  by  sex,  age,  color,  occupa- 
tion, nationality,  marital  condition,  etc.  How  far 
shall  we  go  in  recording  and  tabulating  these  items? 
In  general,  the  principle  to  follow  should  be : — 

1.  Record  only  what  is  useful  for  a  definite  purpose. 

2.  Use  what  you  record.     Otherwise  do  not  record  it. 

3.  Tabulate  as  statistics  only  such  records  as  give  inform- 
ation possessing  public  value  or  guiding  power  over  admin- 
istration. 

Patients'  sex  and  ages,  [for  example,  should  be  ac- 
curately recorded  for  medical  purposes.  To  tabulate 
ages  in  detail  for  an  annual  report,  however,  would 
rarely  be  of  value.  Classification  into  '^men,  women 
and  children"  is  usually  suflScient.  Occupations, 
when  accurately  recorded  by  industry  and  process,  are 
of  high  value  in  correlation  with  disease.  If  loosely 
recorded  and  published,  as  in  many  annual  reports, 
merely  as  a  long  list  by  themselves,  they  are  as  a  rule 
not  worth  the  paper  they  are  printed  on. 

A  general  Dispensary  should  record  and  tabulate  at 
least  the  following : — 


228  DISPENSARIES 

New  Persons  should  be  subdivided  by  clinics  and  by 
Age  and  Sex.  A  certain  age,  usually  12,  14  or  16  (the 
legal  working  age  in  the  state)  is  taken  as  the  dividing 
line  between  ^'Adults"  and  ^'Children."  All  persons 
above  this  age  should  be  tabulated  as  Men  or  Women; 
all  under  this  age  as  '^  Children, ''  their  classification 
into  sex  being  usually  unnecessary.  Color  is  important 
to  record  and  tabulate  in  some  sections  of  the  country ; 
elsewhere  its  tabulation  would  be  of  littleValue. 

Nationality*  (rather  than  birthplace)  is  almost  al- 
ways useful  and  important.  It  may  be  tabulated  for 
the  Dispensary  as  a  whole. 

Occupation  should  be  accurately  recorded,  but  tabu- 
lated only  in  so  far,  or  in  such  particular  clinics,  as 
will  make  the  data  significant  and  useful. 

How  can  the  statistics  of  attendance,  etc.,  be  most 
economically  and  accurately  recorded  and  tabulated? 

In  the  discussion  of  the  admission  system,  it  was 
shown  how  the  daily  record  of  attendance  would  be 
readily  kept  at  the  desks  of  the  admitting  officer  and 
of  the  cashier. 

The  tabulation  form  printed  on  the  opposite  page 
has  been  found  useful  for  recording  these  data.  On 
this  can  be  built  up  the  entire  yearly  statistics  as  fol- 
lows : — 

*  In  recording  Nationality,  use  a  practical,  not  a  technical  definition. 
Thus,  Syrians  should  be  recorded  as  such,  not  as  Turks;  Jews  as  Russian 
Jews,  Pohsh  Jews,  etc.,  not  merely  as  Russians  or  Poles.  Persons  born 
in  America  of  foreign  parents  should  be  suitably  recorded,  as  in  the 
United  States  Census. 


5  Month  of                                           ,19 

ATIENTS 

0  Former  Dept. 

Total 
Visits 

INTERCHANGE 
OF 

s  Year 

Previously 

here  this 

Year 

TRANSFER 

P 

en 

TOTAL 

l»Kdbr 

Amwered 
to 

Ua- 
aaswercd 

Ob 

Spoilt 

*""-! 

l~- 

Dav                      Average  Visits  per  Patient 

way                           .rivciogc    y  .0  ic>  j  i^ 

Fort 


Dispensary 

SfofJcfir-oI  Rpnr>rf  fnr                                                                                     Dfinnrtmfint  Hiirinff  Mnnth   nf 

19 

Physician  nr  Siirgpon  in  Charge,  T)r.                                             Assistants 

Days 

of 

Month 

NEW   PATIENTS 

OLD  PATIENTS 

Total 

Patienia 

to  a 

Deft. 

OLD  PATIENTS 

B.lurnini  10  Fora.r  D.p.. 

Total 
Vllila 

INTERCHANGE 

OF 

TRANSFERS 

By  Admiiiioo  Desk 

By  Transfer  from  Physician 

First  Time  This  Year 

Previously 

liere  tliis 

Year 

M.= 

Women 

a,i,d,„ 

TOTAL 

M.. 

w™,. 

Childr., 

TOTAL 

Mc, 

Children 

M.n 

W.n,.n 

Child,.. 

TOTAL 

kmH, 

Ajumd 

Jr^ 

Swdl. 

1 

2 

^-~^                      s 

<y 

4 

5 

.y~\- 

-^^ 

-SM- 

~ 

" 

"X^                        25 

26 

27 

28 

29 

30 

31 

To(bU 

^= 

No.  of  Clinic  Days Average  New  Patients  per  Day                    Avprag^  Visits  per  Dnv 

Average  Visits  per  Patient                   | 

RECORDS   AND  STATISTICS 


229 


1.  The  Daily 
Attendance 
Sheet 


The  Month- 
ly Clinic 
Sheets 


3.  The  Month- 
ly Dispen- 
sary Sheet 


4.  The  Yearly 
Clinic 
Sheets 


5.  The  Yearly 
Dispensary 
Sheet 


1.  Copy  each  day,  on  this  sheet,  the  number  of  new 
persons  classified  by  age  and  sex  as  above  specified; 
the  number  of  transfers  classified  as  indicated  and  the 
number  of  visits  at  clinics.  This  sheet  when  totalled 
shows  the  total  attendance  and  all  the  other  details  for 
that  day,  and  constitutes  a  permanent  record. 

2.  Have  a  sheet  for  each  cUnic,  similarly  ruled,  but 
headed  with  the  name  of  a  particular  cUnic  written  in, 
and  with  31  lines;  each  day  post  the  total  of  the  at- 
tendance of  that  clinic  on  that  clinic  sheet;  at  the  end 
of  the  monih  this  sheet  can  be  totalled.  The  statistics 
of  the  cHnic  are  thus  given  for  that  month. 

3.  Have  another  sheet  ruled  in  the  same  way  but 
headed  with  the  name  of  a  month,  and  a  line  for  each 
day  as  in  No.  2.  The  total  attendance  for  all  clinics  is 
copied  on  this  sheet  from  the  daily  sheet  at  the  close  of 
each  day.  When  totalled  at  the  end  of  the  month,  thii 
gives  the  total  attendance  for  the  month  in  the  whole 
Dispensary. 

4.  A  sheet  for  each  clinic  exactly  like  No.  2;  but  only 
twelve  Hnes  are  used.  This  will  show  for  each  cHnic 
the  data  for  the  months  of  the  year  and  the  bottom  Une 
will  show  the  totals  for  the  whole  year  in  this  clinic. 
There  will  be  as  many  sheets  as  there  are  chnics. 

5.  A  sheet  hke  No.  3.  Twelve  lines  only  are  used. 
The  footing  of  each  of  the  Monthly  Dispensary  Sheets 
fill  one  line  on  this  Yearly  Sheet.  The  bottom  fine 
shows  the  totals  for  the  whole  Dispensary  for  the  year. 


The  point  in  the  above  scheme  is  to  avoid  the  re- 
copying  of  the  original  data  when  making  up  totals, 
and  to  make  each  sheet  when  finished  a  permanent 
record,  so  it  is  not  necessary  to  recopy  it.  The  sheets 
can  be  either  loose  leaves  in  a  binder  or  pages  in  a 
book.  The  former  plan  is  preferable.  One  ruled 
form,  with  the  proper  blanks  for  top  headings,  does  for 
all  five  sheets.  Only  one  printing  is  necessary,  but 
different  colored  papers  are  convenient  for  each  of  the 


230  DISPENSARIES 

five  types  of  sheet.  In  the  course  of  a  year  will  be 
required  about  300  copies  of  No.  1,  12  of  No.  3,  1  of 
No.  5  and  twelve  times  as  many  of  Nos.  2  and  4  as 
there  are  clinics.  These  forms  have  worked  admirably 
both  in  a  large  Dispensary  receiving  over  100,000  visits 
a  year  and  in  a  small  one  receiving  only  5,000. 

The  special  interests  of  particular  communities, 
institutions,  or  physicians,  will  cause  various  Dis- 
pensaries to  record  and  tabulate  additional  items. 
Almost  any  amount  of  data  could  be  recorded,  but 
we  shall  not  waste  effort  if  we  follow  the  principle  of 
recording  or  tabulating  only  data  which  are  useful, 
usable  and  used.  This  principle  applies  to  one  im- 
portant medical  adjunct,  the  index  of  diseases  treated. 
A  good  diagnosis  index  is  an  expensive  thing  to  main- 
tain. The  first  requirement  is  a  well-worked  out 
classification  of  diseases.  There  is  the  so-called 
International  Classification  and  various  special  classi- 
fications prepared  by  different  organizations.  In  any 
Dispensary  it  should  be  considered  whether  it  is  worth 
while  to  keep  a  complete  diagnosis  index.  Some  in- 
stitutions are  expending  considerable  sums  for  clerical 
service  keeping  up  a  diagnosis  index  which  is  practi- 
cally never  used.  The  services  of  this  clerk  might  be 
much  more  valuable  if  used  in  other  ways.  A  diagno- 
sis index  should  not  be  kept  up  because  of  a  feeling 
that  it  might  be  useful  or  as  an  effort  toward  self-re- 
spect. Usually  the  fact  is  that  certain  departments  or 
physicians  may  occasionally  utilize  such  an  index  for 
clinical  research,  others  rarely  if  ever. 

The  problem  may  often  be  solved  by  keeping  a 


RECORDS  AND  STATISTICS  231 

diagnosis  index  by  clinics,  each  clinic  for  itself;  the 
clinic  manager  or  clerk  being  responsible  for  the  work. 
A  further  simplification  is  practicable,  viz.,  any  mem- 
ber of  the  staff  may  ask  that  for  a  definite  purpose,  all 
cases  of  a  certain  disease  or  group  of  diseases  be  in- 
dexed for  a  certain  period.  This  could  be  indicated 
by  a  '^D"  or  other  mark  opposite  the  diagnosis  to  be 
recorded  and  a  similar  mark  or  a  ^^ signal"  on  the 
outside  envelope  or  folder,  if  such  is  used,  to  call 
attention  to  the  item  as  needed.  The  mark  can  be 
checked  as  recorded  to  avoid  confusion  and  duplica- 
tion. Without  doubt  the  ideal  is  a  complete  and 
well-ordered  diagnosis  index  of  all  cases.  A  well 
trained  clerk  under  medical  supervision  is  necessary 
to  keep  up  a  large  index  of  this  kind,  if  it  is  to  be 
practically  useful  for  medical  research. 

A  word  should  be  said  of  certain  records  and  statis- 
tics which  must  be  kept  in  the  clinics  themselves,  as 
distinguished  from  those  secured  at  the  central  ad- 
mission desk.  Such  are  statistics  of  operations  per- 
formed, suitably  classified,  and  of  laboratory  and  X- 
ray  departments.  The  general  plan  to  follow  is  to 
provide  the  departments  with  convenient  forms  for 
recording  the  items,  having  these  turned  in  to  the 
central  office  monthly.  The  chief  items  which  should 
be  recorded  and  tabulated  in  the  appropriate  climes 
are: — 

Number  of  operations  performed,  specifying  nature  and 
anaesthetic  (Surgical,  G.  U.,  Gyn.,  Throat  and  Ear,  Eye, 
Dental  Clinics). 

16 


232  DISPENSARIES 

Number  of  Eye-glasses,  Orthopedic  or  Surgical  appli- 
ances provided  (Eye,  Orthopedic,  Surgical  and  other  clinics). 

Number  of  Diagnostic  Proceedures  (Lumbar  Puncture, 
etc.).     (Medical,  Children's,  Nerve  and  other  clinics.) 

Number  of  the  chief  Laboratory  tests,  classified.  The 
Laboratory  Report  form  should  show  the  nufiiber  of  each 
of  the  tests  performed  and  preferably,  also,  the  chnics  from 
which  referred. 

Number  of  .X-ray  plates  and  treatments.  It  is  well  to 
classify  the  X-ray  plates  by  size,  to  record  bismuth  and 
fluoroscopic  cases  separately;  and  when  X-ray  fees  are 
charged,  to  classify  according  to  the  fees  received  from  each 
class  of  work.  Number  of  plates  must  be  correlated  with 
number  of  patients,  in  order  to  give  the  most  intelligent  idea 
of  the  work  done. 

One  final  point,  applying  to  all  record-taking  and 
record-using: — The  people  who  collect  the  original 
data  are  rarely  the  same  as  the  poeple  who  analyze 
them,  think  about  them,  and  draw  conclusions  from 
them.  The  nurses,  social  workers  and  clerks  who 
gather  raw  statistical  material,  or  make  records  on 
which  statistics  are  based,  often  have  a  mass  of  detail 
work  to  do  (necessary  tasks!)  without  being  afforded 
opportunity  to  see,  later,  the  meaning  and  results  of 
that  work.  The  persons  who  make  the  analyses  and 
interpretations  will  gain  more  eager  co-operators  and 
ultimately  better  statistics  if  they  will  see  to  it  that 
their  helpers  learn  something  of  the  results  and  their 
value  to  the  institution  or  to  the  community.  It  is 
well  that  those  who  do  the  chores  should  share  in  the 
fun. 


FOLLOW-UP  SYSTEMS  233 


CHAPTER   XIV 
FOLLOW-UP    SYSTEMS  ^ 

In  the  old-fashioned  dispensary  clinic  there  were  a 
few  medical  high  spots,  known  as  ^interesting  cases"; 
but  the  general  average  of  the  ^'routine  cases"  were 
patients  who  came  in  to  see  the  doctor  and  obtained 
advice  and  a  prescription.  Whether  they  pursued 
the  treatment  nobody  knew.  Obviously  this  meant 
a  large  amount  of  work  done  by  the  doctor  for  which 
no  results  in  achieving  the  cure  of  disease  could  be 
demonstrated  and  perhaps  an  equally  great  waste  of 
time  on  the  part  of  the  patient.  In  some  instances 
one  or  two  visits  to  the  doctor  may  be  all  that  are 
necessary,  but  the  point  is  that  the  old-fashioned 
clinic  did  not  organize  itself  so  as  to  discriminate 
between  the  patients  who  needed  continuous  observa- 
tion and  those  who  did  not. 

These  points  have  been  shown  by  actual  study  of  a 
number  of  clinics.  Thus  in  a  general  medical  clinic 
it  was  found  that  sixty-three  per  cent  of  the  patients 
paid  only  one  visit.  When  the  physicians  looked 
over  the  records  and  took  out  only  those  cases  in 
which  it  appeared  that  further  visits  were  probably 
necessary,  it  was  still  found  that  forty-five  per  cent 
of  these  did  not  return.  In  clinics  treating  gonorrhea  ■ 
it  was  found  that,  unless  special  provision  was  made,  , 
thirty-three  and  one-third  per  cent  did  not  return 


234  DISPENSARIES 

after  the  one  visit.  In  a  clinic  treating  syphilis  with- 
out a  follow-up  system,  twenty-eight  per  cent  of  the 
syphilitics  paid  only  one  visit  and  forty-two  per  cent 
paid  not  more  than  two.  In  a  gynaecological  clinic 
it  was  found  that  of  the  women  who  were  advised  to 
have  operations  only  one  in  twenty  secured  them  until 
a  follow-up  system  was  started.  In  a  throat  clinic  it 
has  been  found  that  of  the  children  who  were  advised 
to  have  tonsils  and  adenoids  removed  and  who  had 
appointments  for  operation  made  with  the  consent  of 
their  parents,  one-half  did  not  return  to  have  the 
operation  performed.  In  a  clinic  for  mental  disorders, 
where  practically  all  the  patients  have  long-term 
diseases,  twenty-seven  per  cent  were  found  to  pay 
only  one  visit;  in  a  clinic  for  eye  diseases,  fifty  per 
cent  of  the  patients  for  whom  glasses  were  prescribed 
did  not  obtain  them;  in  a  surgical  clinic  thirty-five 
per  cent  of  the  cases  paid  only  one  visit. 

Follow-up  systems,  so  called,  have  been  devised  to 
correct  these  wastes.  The  term  has  been  used  in  two 
senses  between  which  it  is  important  to  discriminate. 
First,  the  follow-up  system  has  been  applied  to  a 
plan  proposed  by  the  Clinical  Congress  of  Surgeons  of 
North  America,  applying  especially  to  major  surgical 
cases  in  a  hospital.  The  aim  is  to  ascertain  at  the  end 
of  a  specified  period  after  cases  have  been  discharged 
from  the  wards,  the  condition  of  these  patients. 
This  means  in  practice,  finding  out  at  the  end  of  the 
year,  through  correspondence  or  through  securing  the 
patient's  personal  visit  to  the  hospital,  the  end-result 
of  the  operation  and  the  present  condition  of  the 


FOLLOW-UP  SYSTEMS  235 

patient.  This  commendable  plan  has  undoubted 
value  in  supplying  medical  information.  It  will 
benefit  some  patients  directly;  it  may  indirectly  help 
many  others;  and  it  will  stimulate  and  instruct  the 
physicians,  surgeons,  and  the  hospital  administration. 


"THE  PATIENT  CAME,  GOT 
AN  EXAMINATION  AND  A  DIAGNOSIS" 


BUT 


I    "HE  N 


EVER  CAME  BACK." 


Out  of  403  Patients     nil^^^iTHII^B        180  or  459b 
Treated  in  a 


",-;""      .    I  mm  I^^^H  Paid  Only  One  Visit 
Women  s  fi^edical  Clinic  i  ^„^  H^^^^H 

During  Three  Months    L_LH^H         *"  ^^^  ^''"'' 

HOT  ALL  OF  THE  WORK  fiOHE  FOR  THESE  180  PATIENTS 
WAS  WASTED,  BUT  ^OST  OF  IT  WAS 

To  Reduce  Waste       1      [  Efficient 
'"«'"»  [  =  j  Medical 

A  Follow-Up  System  J      [  Service 


The  second  sense  of  the  word  follow-up  system, 
means  following  the  patient  during  the  course  of  his 
treatment,  or  during  the  year  or  more  after  his  dis- 
charge from  the  hospital  ward  or  the  dispensary  clinic. 
Under  such  a  system  we  do  not  merely  find  out  what 
happens  a  certain  time  after  treatment  has  ceased; 


236 


DISPENSARIES 


we  keep  in  touch  with  the  patient  during  the  course  of 
treatment  and  are  able  to  help  to  make  things  go  well. 
The  following  chart  illustrates  the  contrast: 

HOW  ASCERTAIN  END-RESULTS? 

FISH-UP  OR  FOLLOW-UP? 


TOFI$H-UP 

4  PATIERT'S  CONDITION 

AT  THE  END  OF  A  YEAR 


FINDING 
AN  EPITAPH 


TO  FOLLOW-UP 

A  PATIENT  THROUGH 

THE  YEAR 


FORESTALLING 
AN  UNDERTAKER 


The  vital  point  of  a  follow-up  system  in  a  Dispen- 
sary is  not  the  reduction  of  the  number  of  patients 
who  pay  only  one  visit.  Too  much  stress  may  be 
laid  on  this  point.  The  vital  element  is  having  a 
system  by  which  discrimination  shall  be  made  in  the 
case  of  every  patient,  as  to  whether  or  not  this  patient 
ought  to  return  or  need  not  return,  for  further  treat- 
ment. The  two  essential  principles  which  should 
govern  every  follow-up  system  are  in  fact  these: 

1.  In  the  case  of  every  visit  of  every  patient  to  the  clinic, 
the  physician  should  decide  two  questions: 
(a)  Should  the  patient  return? 


FOLLOW-UP  SYSTEMS 


237 


(b)  If  not,  is  he  discharged?  (If  discharged,  how  shall 
the  outcome  of  the  case  be  summarized  on  the  medical 
record?) 

(c)  If  he  is  to  return,  on  or  about  what  date  is  his 
return  desired? 

The  patient  should  he  told  hy  the  doctor  whether  or  not  he 
ought  to  return  for  further  treatment.  If  he  should  return, 
the  date  should  be  stated  to  him. 

2.  If  the  patient  does  not  return  when  he  has  been  told 
to  do  so,  he  must  be  followed  up  by  mail,  or  by  personal 
visit  to  such  an  extent  as  a  responsible  person  deems  neces- 
sary. 

The  mechanisms  for  making  these  principles  effect- 
ive are  simple  and  inexpensive : — 

1.  A  date  index. 

2.  A  date  card. 

3.  An  appointment  slip  or  card. 

4.  Follow-up  forms. 


AO                                                                                                      Nil" 

• 

191 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

J»n. 

Jan. 

Feb. 

Fab. 

Mar. 

Mar. 

Apr. 

Apr. 

Ma, 

May 

June 

June 

i 

16 

17 

18 

19 

20 

21 

22 

23 

24 

.25 

26 

27 

28 

29 

30 

31 

i 

Jan. 

Jan. 

Feb. 

Feb. 

Mar. 

Mar. 

Apr. 

Apr. 

May 

Mjy 

-June 

June 

y^    SA, 

Form  No.  12 


238 


DISPENSARIES 


The  most  essential  one  of  these  is  the  date  card.  A 
form  which  has  been  widely  used  in  cUnics  is  printed 
here  (No.  12).     Half  the  year  is  on  one  side  of  the  card 


Form  No.  12  (reverse  side) 

and  half  the  year  on  the  other.  The  name  and  num- 
ber identifying  the  patient  are  put  on  the  card  and  to 
indicate  the  date  of  desired  return  it  is  simply  neces- 
sary to  make  a  check  or  line  in  the  square  correspond- 
ing to  the  desired  date.  Another  form  (No.  13)  en- 
ables the  entire  year  to  be  put  on  one  side  of  a  card. 


At). 

NO 

__ 

■7- 

«  1 

-p- 

-7- 

-77 

•  1 

"7" 

— 

— 

To" 

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It 

19 

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.7 

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<• 

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ST 

t* 

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^ 

^ 

■■ 

■" 

"■ 

^ 

"" 

^ 

■" 

■— 

— 

— 

~ 

MAW. 

— 

— 

—" 

^ 

M 

APm. 

"" 

^ 

*" 



■AV 

— 

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JUM. 

— 

■Ml 

^M 

mimi 

M 

JUl- 

■■ 

^ 

^ 

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T 

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— 

— ^ 

^ 

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1^ 

^ 

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not. 

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— 

— 

^^ 

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T 

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1« 

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r»» 

Form  No.  13  (goes  on  a  3  x  5  card) 


FOLLOW-UP  SYSTEMS  239 

A  date  index  is  merely  a  filing  arrangement  in  which 
the  cards  are  filed  under  the  date  on  which  the  patients 
are  expected  to  return.  Date  indexes  of  many  kinds 
have  been  devised;  the  most  obvious  is  simply  the 
card  filing  drawer  with  colored  dividers  marking  the 
days  of  the  month.  The  patients  who  are  to  return 
on  a  certain  date  have  their  cards  put  just  behind  the 
divider  indicating  that  date.  The  visible  indexes  have 
many  points  of  practical  convenience  though  they  are 
slightly  more  expensive  to  install.  The  ''Index  Visi- 
ble/^ invented  by  Prof.  Irving  Fisher,  has  a  strip  of 
metal  on  which  the  date  cards  are  attached  by  a  simple 
device.  One  strip  can  be  used  for  each  day  of  the 
month,  or  in  a  small  clinic  each  strip  may  be  divided 
so  as  to  allow  for  several  days.  The  ''Rand"  visible 
system  gives  practically  the  same  result  as  the  other 
with  a  different  mechanical  arrangement. 

When  a  patient  first  comes  to  the  clinic  the  date 
card  is  filled  out  with  the  patient's  name  and  identi- 
fying number;  and  this  date  card,  if  filled  out  by  a 
clerk,  goes  to  the  physician  with  the  patient's  medical 
record.  If  the  physician  fills  out  the  date  card  him- 
self, he  has  it  already  in  hand.  In  either  case  he  marks 
on  the  card  a  check  or  line  on  the  date  on  which 
he  desires  the  patient's  return.  If  the  patient  is  to 
be  discharged  or  is  to  be  transferred  finally  to  another 
clinic  or  institution,  the  word  "discharged"  is  written 
on  the  date  card.  The  date  card  then  goes  back  to 
the  filing  cabinet  and  is  either  put  into  the  file  under 
the  date  of  the  patient's  expected  return  or  is  filed 
away  with  the  cards  of  discharged  patients. 


240  DISPENSARIES 

In  a  large  clinic  it  is  generally  desirable  to  have  a 
date  division  for  each  day  of  the  month.  Thirty-one 
divisions  plus  a  few  additional  ones  for  extra  cards, 
etc.,  will  be  enough.  In  a  small  clinic,  or  where  the 
diseases  treated  are  such  that  they  do  not  have  to  be 
followed  up  closely  by  days,  a  division  by  weeks  may 
be  preferable.  The  scheme  can  be  readily  adapted 
to  long-term  chronic  cases  as  well  as  to  cases  of  acute 
disease. 

In  any  case  the  operation  of  the  date  index  is  as 
follows:  On  each  clinic  day  the  patients  who  return 
have  their  date  cards  looked  up  and  taken  out  of  the 
index.  These  cards  go  to  the  doctor  and  are  again 
marked,  either  ^^ discharged"  or  with  the  date  of  the 
next  desired  return.  When  a  patient  does  not  return 
on  the  day,  or  during  the  week  indicated,  the  date 
card  of  course  remains  in  its  place  in  the  index.  Thus 
at  the  end  of  the  day  (or  week)  the  names  of  all  pa- 
tients who  have  not  returned  are  known.  Then  the 
follow-up  efforts  may  begin  and  a  post-card  or  a  letter 
be  sent  to  the  patient. 

It  is  a  distinct  aid  in  promoting  the  return  of  patients 
to  give  each  an  Appointment  Card  as  a  memorandum, 
and  the  same  may  also  serve  educational  ends.  An 
example  of  such  a  card  is  given  below  (Form  No.  14). 

Generally  it  is  desirable  to  wait  from  three  days  to 
a  week  after  the  date  on  which  the  patient  was  sup- 
posed to  return  before  sending  the  post-card,  as 
weather  or  other  conditions  may  have  delayed  the 
patient  from  coming  on  the  exact  day.  Cases  which 
are  medically  urgent  can  be  so  marked  by  the  physi- 


FOLLOW-UP  SYSTEMS  241 


DISPENSARY: 

Please  return  on 

To  see  the  Doctor  in  the Dept, 


KEEP 
THIS 
APPOINTMENT! 


A  visit  at  the  time  the  Doctor  advises  may  save  many 
visits  later  on.  The  Doctor  asks  you  this  for  your  benefit. 


roan  7»  sii-«-i» 


Form  No  14. 


The  man  who  runs  a  big  factory  has  oilers  and  mechanics  who 
go  over  every  machine  regularly.  They  do  not  waut  until  a  machine 
breaks  down. 

Sickness  means  that  the  machinery  of  our  body  has' broken  down 
somewhere.       Most  people  do  not  go  to  a  doctor  until  this  happens. 

This  is  a  mistake.  If  every  grown-up  person  whether  he  were 
sick  or  well,  went  to  a  doctor  once  a  year,  and  every  child  were 
taken  to  a  doctor  once  in  six  months,  a  great  deal  of  sickness  would 
be  prevented  and  life  would  be  prolonged. 

See  a  doctor  at  regular  intervals,  to  examine  you  and  give  you 
advice  for  your  health. 


Form  No.  14  (reverse  aide) 


242  DISPENSARIES 

cian  or  certain  diagnoses  can  be  understood  to  be 
always  urgent,  so  as  to  start  follow-up  without  waiting 
the  usual  period. 

In  a  large  clinic  the  follow-up  system  requires  the 
assistance  of  a  clerk.  A  post-card  or  letter  sent  to  the 
patient  and  not  causing  him  to  return,  may  be  followed 
by  a  second  notice.  In  some  clinics  a  reply  post-card 
has  been  sent  in  certain  instances,  in  order  to  furnish 
information  as  to  why  the  patient  did  not  return  and 
what  the  condition  is.  But  the  reply  post-cards 
should  be  used  with  selected  cases  only,  if  at  all. 
After  one  card  or  letter  has  failed,  it  is  well  to  have 
the  case  considered  again  by  the  physician,  or  to  have 
the  cases  classified  according  to  gravity  of  diseases; 
the  point  being  to  determine  which  cases  shall  be 
dropped  and  which  further  followed.  The  home  visit, 
made  by  a  social  worker,  visiting  nurse,  or  a  well- 
supervised  volunteer,  is  the  final  resort  after  the  mails 
have  proven  ineffectual. 

Post-cards,  in  which  only  a  few  items  had  to  be 
filled  in,  have  been  generally  employed  by  Dispen- 
saries, in  their  follow-up  systems;  except  in  clinics 
treating  venereal  disease  (see  below).  Letter  forms 
are  however  distinctly  more  effectual,  and  cost  only 
a  very  little  more,  in  stationery  and  labor.  Since  the 
War,  rates  of  postage  on  post-cards  and  letters  are  the 
same  within  the  local  district.  Multigraphed  letter 
forms  can  be  cheaply  prepared,  and  adapted  to  a 
variety  of  cases  by  suitable  wording.  The  Boston 
Dispensary  uses  about  ten  different  forms,  in  three 
series;  one  designed  for  children,  one  for  adults,  and 


FOLLOW-UP  SYSTEMS  243 

the  third  for  venereal  cases.  Within  each  series  the 
different  forms  are  meant  for  different  types  of  cases, 
acute,  chronic,  needing  laboratory  tests,  etc.  Two 
sample  forms  are  printed  herewith. 

DISPENSARY 
Street  and  Number 

Department Room  No 

To: 

Please  return  to  see  the  Doctor  before  10  A.  M.  on 

Bring  your  Dispensary  admission  card  with  you. 
Form  No.  15. 

Bear 

The  Doctor  wants  you  to  return   to    the 

Clinic  on of  next  week. 

If  you  are  well,  or  if  for  any  other  reason  you  do  not  plan  to  return, 
please  send  a  letter  so  we  will  know  how  you  are. 
This  notice  is  sent  to  you  for  the  sake  of  your  health. 

Very  truly  yours, 

Dispensary Clinic. 

By 

Date 191.. 

Form  No.  16. 

The  reasons  which  patients  give  for  not  returning 
when  asked  to  do  so  are  well  worth  noting.     The 


244  DISPENSARIES 

reason  stated  may  not  always  be  the  real  one,  but  it 
indicates  the  state  of  mind  of  the  patient  and  some- 
thing of  the  impression  actually  produced  by  the 
advice  given  at  his  last  visit  to  the  clinic.  Valuable 
suggestions  for  more  efficient  clinic  management  may 
be  secured  from  such  data. 

It  is  found  that  of  the  patients  who  are  told  to  come 
back  for  treatment  from  seventy-five  per  cent  to  over 
ninety  per  cent  may  be  brought  back  by  a  follow-up 
system.  The  proportion  will  vary  in  different  com- 
munities and  in  different  clinics  of  the  same  Dispen- 
sary. The  mails  will  bring  back  the  majority.  Home 
visits  should  not  be  necessary  in  more  than  ten  per 
cent  to  twenty  per  cent  of  the  cases. 
j'  In  certain  types  of  cases,  as  of  gonorrhea  or  syphilis, 
'the  use  of  post-cards  is  questionable.  Here  letters 
should  always  be  used  instead.  Some  Dispensaries 
have  a  special  envelope  for  these  cases  not  bearing 
the  name  of  the  institution,  but  merely  a  post-office 
box  or  a  street  number.  Inasmuch  as  incorrect  or 
falsely  given  addresses  of  patients  are  an  item  which 
should  be  known,  it  is  important  that  all  letters  should 
carry  some  address  on  the  envelope  so  that  if  unde- 
livered the  post-office  will  return  them. 

The  superintendent  who  has  to  look  to  the  expense 
account  will  bear  in  mind  that  where  a  fee  for  each 
visit  is  charged  the  patient,  the  follow-up  system  pays 
for  itself  in  considerable  measure.  The  date  cards 
cost  about  $5  per  thousand  and  a  visible  index  from 
$8  to  $25,  depending  on  size.  Not  over  half  the 
time  of  a  clerk  will  be  necessary  for  the  follow-up 


FOLLOW-UP  SYSTEMS  245 

system  in  a  large  clinic.  The  total  current  expense 
properly  chargeable  to  the  system  would  range  from 
seventy  cents  to  one  dollar  per  day  including  post- 
cards and  salary,  in  a  clinic  receiving  an  average  of 
fifty  visits.  It  may  readily  be  seen  that  if  patients 
pay  ten  cents  per  visit  and  if,  as  in  most  cases,  three- 
quarters  pay  the  fee,  a  comparatively  small  addition 
to  the  number  of  return  visits  would  more  than  pay 
for  the  follow-up  service.  The  cost  of  the  care  of  the 
additional  patients  will  also  have  to  be  met,  but  there 
is  little  extra  expense  in  caring  for  a  moderate  number 
of  extra  patients  since  all  fixed  charges  are  covered. 
This  assumes  that  medicines  are  charged  for  at  fees 
that  cover  the  cost. 

The  follow-up  system  in  a  clinic,  as  will  be  seen, 
includes  elements  of  mere  clerical  work  and  also 
questions  requiring  judgment.  The  physician  will 
decide  some  of  the  latter,  but  others  he  may  not  have 
time  for.  The  detailed  execution  of  the  daily  follow- 
up  routine  should  be  left  to  a  clerk,  but  she  should  be 
supervised  closely  by  another  person,  a  nurse  espe- 
cially trained  for  such  medical-social  tasks,  or  (more 
usually  in  practice)  by  a  social  worker.  Decision 
upon  the  various  cases,  as  to  dropping  or  continuing 
them,  sending  further  post-cards,  etc.,  depends  so 
much  on  the  physician's  or  social  worker's  personal 
knowledge  of  the  case  that  it  cannot  wisely  be  taken 
away  from  the  clinic  and  put  in  a  central  office  for 
the  whole  Dispensary.  The  purely  clerical  duties  of 
addressing  post-cards,  etc.,  can  be  centralized  with 
advantage,  but  the  follow-up  system  as  a  whole  will 


246  DISPENSARIES 

be  made  mechanical  if  taken  out  of  the  hands  of  those 
who  have  direct  knowledge  of  the  patients. 

The  actual  effect  of  a  follow-up  system  in  promot- 
ing clinical  efficiency  is  remarkable.  It  secures  con- 
tinuity of  treatment  in  the  large  proportion  of  cases; 
it  places  the  '^medical  material"  of  an  out-patient 
clinic  under  the  control  of  the  physician;  it  renders 
possible  the  systematic  study  and  treatment  of  chronic 
cases.  The  contrast  between  a  clinic  with  and  with- 
out a  follow-up  system  can  be  partially  shown  by 
statistics.     Many  more  illustrations  could  be  given. 

"BEFORE  AND  AFTER  TAKING"" 

A  Follow-up  System 

In  Relation  to  Visits 

Per  cent  of  gonorrheal  patients  making  more 

than  1  or  2  visits 

A/r  1    n   n  nv  •«       /  1911-12  (before) 37.6% 

Male  G.  U.  Climc       |  ^q^^_^^  ^^^^^^^  > ^g  ^^^ 

Per  cent  of  patients  making  more  than  1  or 

2  visits 

,,  J.    ,  ^,.   .  /  1914  (before) 51% 

Medical  Chmc  |  ^^^^  \^^^^^^  [ ^^g 

In  Relation  to  Advice 

Per   cent   of   patients   who   secured   glasses 
advised 

^      ^,.  .  ( 1911-12  (before) 50% 

bye  Clmic  <^  1914-15  (after) 97% 

Per  cent  of  patients  who  secured  operation 

advised 

/-.  1     •    ir^r   •    /  1913  (before) 7%  secured  it 

Gynaecological  Chmc  |  ^g^^  y^^^^  [ ^5^^  ^^^^^^  ^^ 

Of  all  means  of  bringing  the  patient  back  to  the 
clinic,  one  stands  out  supreme.  No  post-card,  no 
home  visit,  is  as  effective  as  the  definite  impression 
made  by  the  doctor  upon  the  patient,  especially  at  the 
first  visit.     Explanations  by  the  doctor  to  the  patient 


FOLLOW-UP  SYSTEMS  247 

of  the  desirability  of  return,  of  the  importance  of 
curing  the  disease,  and  an  explicit  indication  of  the 
date  on  which  a  return  is  desired,  make  all  the  differ- 
ence in  the  world  in  promoting  the  patient's  revisit. 
A  distinct  element  in  the  value  of  the  date  card  sent 
in  to  the  doctor  lies  in  its  unconscious  stimulation  to 
him,  leading  to  definite  decisions  as  to  the  need,  char- 
acter and  dates  of  future  treatment.  With  an  organ- 
ized follow-up  system,  the  physician's  power  as  a 
teacher  and  guide  is  enhanced;  surpassing  that  in 
private  practice,  except  where  an  intimate  relation- 
ship as  family  physician  exists.  The  clinic  is  no 
longer  passive,  but  is  rendered  a  militant  agent  for 
achieving  cure  of  disease  and  for  promoting  health. 


17 


248  DISPENSARIES 


CHAPTER   XV 
EFFICIENCY  TESTS 

We  need  efficiency  tests,  because  in  Dispensaries 
as  everywhere  else  we  must  have  facts  as  well  as 
faith.  Are  we  living  up  to  a  high  professional  stand- 
ard in  the  care  of  patients?  Only  impersonal  exam- 
ination of  the  work  done  for  these  patients  can  answer 
this  question.  Are  we  giving  adequate  service  to  the 
poor  in  whose  behalf  we  solicit  charitable  contribu- 
tions? Unless  we  make  efficiency  tests  we  can  only 
respond  by  quoting  utterances  of  gratitude.  We 
cannot  tell  how  many  patients  were  not  ^' grateful.'^ 

Efficiency  tests  of  Dispensary  work  are  not  difficult 
in  method.  Their  execution  is  sometimes  laborious; 
sometimes  quick  and  easy.  It  depends  upon  what 
and  how  much  we  are  testing.  This  chapter  will 
briefly  review  some  of  the  methods  which  have  been 
found  profitable  and  economical  of  application,  and 
which  have  been  used  in  several  institutions  for  the 
purpose  of  informing  physicians,  administrators  and 
trustees,  of  the  results  they  were  achieving  in  their 
dispensary  work. 

The  most  useful  rough-and-ready  test  is  the  exam- 
ination of  the  number  of  visits  paid  by  patients. 
Visits  per  patient  is  a  useful  test  of  work  done,  a  test 
which,  like  an  inexact  yardstick,  must  be  used  with 


EFFICIENCY  TESTS 


249 


caution  and  checked  by  a  discriminating  sense  before 
final  conclusions  are  drawn. 

Visits  per  patient  can  be  determined  in  two  ways. 
We  have  recorded,  let  us  say,  the  total  attendance  at 
a  clinic ;  we  also  have  the  number  of  new  clinic  patients, 
that  is,  the  number  of  new  persons  sent  to  the  clinic, 
plus  transfers  thereto.  The  number  of  visits  divided 
by  the  number  of  new  clinic  patients  gives  the  visit 
per  patient.  In  the  institution  as  a  whole,  the  total 
of  all  visits  should  be  divided  by  the  number  of  new 
clinic  patients.  The  following  table  gives  some  actual 
clinic  figures  as  illustrations : — 


Clinic 


Total 
Visits 


New  Clinic 
Patients 


Average 

Visits  per 

Patient 


Average  Visits 
per  Patient  in 
Same  Clinic  in 
a  Later  Year 


Children's  Medical 

Surgical , 

Gynaecological . . . . 

Dental 

Genito-Urinary. .  . 


14,071 

3,322 

4.2 

11,658 

3,215 

3.6 

7,029 

1,249 

5.6 

4,100 

2,630 

1.6 

11,181 

1,513 

7.4 

4.6 
4.0 
7.5 
1.6 
12.7 


\ 


The  differences  between  clinics  depend  largely  upon 
the  nature  of  the  diseases  treated.  How  does  '^Aver- 
age Visits  per  Patient"  test  efficiency?  The  last 
column  of  the  table  indicates  the  answer.  If  we  com- 
pare the  visits  per  patient  in  the  same  chnic,  one  year 
with  another,  and  see  an  increase,  we  are  evidently 
getting  either  a  change  in  the  medical  constitution  of 
the  clinic  (i.e.,  different  diseases  to  be  treated),  or  a 
difference  in  the  character  of  the  medical  work.  If 
patients  are  coming  back  more  frequently  for  treat- 


250  DISPENSARIES 

ment,  they  are  presumably  securing  better  treatment. 
The  increase  in  the  number  of  visits  per  patient  in  the 
same  clinic  as  compared  with  the  preceding  year,  is  as 
a  rule  proof  of  an  improvement.  All  but  one  of  the 
clinics  in  the  above  table  underwent  certain  changes 
during  the  period  between  the  two  computations. 
Thus,  the  Children's  Medical  and  the  Genito-Urinary 
clinics  mentioned  established  a  follow-up  system, 
there  being  no  other  change  in  staff  or  equipment. 
The  Gynaecological  Clinic  introduced  a  social  worker 
and  a  follow-up  system  as  well.  The  Dental  Depart- 
ment, which  shows  no  change  in  visits  per  patient, 
remained  just  the  same  in  arrangements  and  in  staff. 
The  Surgical  Department  reorganized  its  Staff,  sub- 
stituting long  services  instead  of  frequently  changing 
ones,  thus  bringing  about  more  continuous  treatment 
of  patients. 

Such  tests  are  very  suggestive  and  easy  to  make.  It 
is  best  to  begin  such  tests  with  a  consideration  of 
diseases  under  treatment.  Obviously  in  some  dis- 
eases a  single  or  a  few  treatments  may  be  sufficient 
to  secure  satisfactory  results;  in  others,  there  is  a  long 
period  of  medical  supervision  necessary  and  many 
visits  should  be  paid  to  the  clinic.  Thus  for  any 
refined  testing  of  results  the  diagnosis  must  be  kept 
in  mind.  An  extract  from  a  paper  prepared  by  one 
of  the  writers  for  the  American  Medical  Association 
in  1912  will  illustrate  this  concretely  :^° — 

"In  a  genito-urinary  clinic  the  records  of  the  new  cases 
of  gonorrhea  were  tabulated  for  six  months,  the  tabulation 
being  made  after  the  six  months  were  over  so  that  nothing 


EFFICIENCY  TESTS  251 

was  known  about  the  test  during  the  progress  of  the  work. 
The  number  of  visits  paid  by  each  patient,  as  shown  by  the 
records,  which  in  this  cUnic  are  kept  by  a  paid  clerk,  are 
given  in  Table  1.  The  total  number  of  patients  was  450, 
nearly  all  of  whom  had  acute  gonorrhea. 

TABLE  1.— NUMBER  OF  VISITS  TO  A  CLINIC  BY  FOUR  HUN- 
DRED AND  FIFTY  GONORRHEA  PATIENTS 

No.  of  No.  of 

Visits                                                          Patients  Percentage 

1 215  47.8 

2 70  15.6 

285  63.4 

3 32  7.1 

4 32  7.1 

5. 16  3.6 

80  17.8 

6  to  8 29  6.4 

9  to  12 18  4.0 

Over  12 38  8.4 

.  —    85  18.8 

*'It  will  doubtless  be  agreed  that  small  results  can  be 
obtained  in  a  patient  with  active  gonorrhea  from  a  single 
visit  to  the  clinic,  and  that  if  nearly  one-half  of  these  450 
patients  paid  one  visit  and  never  came  back,  there  is  a 
serious  waste  of  the  physician's  time  and  of  the  institution's 
money. 

*'  These  figures  are  particularly  interesting  because  in  1902 
two  of  the  surgeons  then  in  charge  of  this  same  cUnic  made 
for  a  different  purpose  a  study  of  the  treatments  for  a  period 
of  two  months,  and  of  130  patients  with  acute  gonorrhea 
found  that  eighty,  or  61.5  per  cent,  paid  only  one  or  two 
visits.  This  is  almost  identical  with  63.3,  the  percentage 
obtained  by  this  study  made  ten  years  later.  I  shall  touch 
later  on  some  probable  causes  and  correctives  for  this  waste. 
Certainly  we  should  have  similar  figures  from  a  number  of 
genito-urinary  clinics  and  try  every  possible  method  to  see 


252  DISPENSARIES 

if  the  proportion  of  wasted  effort  cannot  be  diminished. 
The  growing  demand  for  deaUng  effectively  with  the  prob- 
lem of  venereal  disease  renders  the  efficiency  of  genito- 
urinary clinics  a  matter  of  public  importance.  They  need 
to  be  efficient  as  curative  and  prophylactic  agents,  and  as 
safe  and  sane  substitutes  for  the  advertising  quack. 

"Another  illustration  exemplifies  the  value  of  these 
statistical  tests  in  judging  relative  efficiency.  In  a  clinic 
for  diseases  of  the  eye,  two  quarterly  services  were  com- 
pared and  the  number  of  visits  per  patient  tabulated,  sim- 
ilarly, for  the  two  services.  Without  going  into  all  the 
details,  I  will  summarize  the  tabulation  as  follows : 

"In  iritis  cases  the  average  number  of  visits  during  one 
service  was  5.8,  in  the  other  service  10.6. 

"In  cases  of  phlyctenular  keratitis  the  average  number  of 
visits  during  one  service  was  4.7,  during  the  other  service 
8.5. 

"In  473  cases  representing  six  of  the  acute  eye  diseases 
including  those  just  named  (the  cases  being  almost  equally 
divided  between  the  two  services),  the  average  number  of 
visits  paid  per  patient  during  one  service  was  2.4,  during 
the  other  service  4.0.  When  each  of  the  six  diseases  is 
tabulated  separately  the  comparison  makes  in  every  case  in 
favor  of  one  service  and  against  the  other,  the  difference 
ranging  from  25  per  cent  to  over  100  per  cent,  in  the  average 
number  of  visits  paid  per  patient. 

"During  one  service  (to  illustrate  further)  50  per  cent  of 
the  patients  with  iritis  paid  no  more  than  two  or  three 
visits;  during  the  other  service  80  per  cent  paid  more  than 
six  visits.  We  may  question  whether  successful  treatment 
of  an  acute  case  of  iritis  can  be  given  in  two  or  three  visits; 
we  may  be  sure  that  twice  that  number  of  treatments  is  not 
too  much  to  insure  control  of  the  disease  and  saving  of  the 
eyesight.     The  figures  I  have  given  do  not  determine  the 


EFFICIENCY  TESTS  253 

responsibility  for  the  difference  in  efficiency,  but  they  do 
raise  the  question  pointedly." 

Since  ejQficiency  tests  have|been  talked  about  in 
Dispensaries,  Annual  Reports  have  begun  to  show  the 
average  number  of  visits  of  patients  in  the  Dispensary 
as  a  whole,  and  even  to  state  the  figure  for  particular 
clinics.  An  increase  in  the  number  of  visits  per 
patient  is  pointed  out  with  satisfaction.  This  is  a 
hopeful  sign.  A  word  of  precaution  is  here  offered 
against  comparing  visits  per  patient  between  different 
Dispensaries.  Average  visits  per  patient,  for  all 
clinics  together  in  a  large  Dispensary,  is  a  figure  made 
up  of  many  different  elements,  which  will  not  be  the 
same  as  those  in  another  institution.  For  example, 
at  one  Dispensary  there  may  be  a  large  surgical  clinic 
containing  many  minor  accident  cases  which  are 
treated  two  or  three  times  and  no  more.  Another 
Dispensary  will  have  a  great  proportion  of  children, 
feeding  cases  and  chronic  medical  disorders,  each  of 
which  ought  to  be  seen  many  times.  Another  Dis- 
pensary will  have  large  treatment  clinics  for  hydro- 
therapy or  massage.  Such  clinics  receive  no  patients 
except  on  reference  from  other  clinics.  Therefore 
the  number  of  visits  is  swelled,  but  not  the  number  of 
new  persons.  Another  institution  will  have  a  large 
dental  clinic  doing  emergency  work,  rarely  seeing  the 
same  patient  more  than  once  or  twice;  or  large  eye 
clinics  doing  refraction,  where  the  patients  are  usually 
fitted  with  eyeglasses  and  discharged  in  two  visits. 

Thus,  comparison  between  different  Dispensaries, 
based  merely  on  the  average  number  of  visits  per 


254  DISPENSARIES 

patient  of  an  institution  as  a  whole,  is  a  very  unsafe 
indication  of  quality  of  work.  When,  however,  we 
compare  the  same  institution  with  itself  year  after 
year,  knowing  as  we  do  that  the  list  of  clinics  and 
their  general  constitution  has  remained  the  same,  we 
have  a  distinctly  useful  comparison. 

If  we  compare  a  particular  type  of  clinic  with  an- 
other of  the  same  kind  in  a  different  institution,  we 
have  a  little  more  trustworthy  comparison  for  indi- 
cating quality  of  work.  But  here  again  caution  must 
be  exercised,  for  two  clinics  bearing  the  same  general 
title  may  vary  in  medical  constitution.  Only  when 
we  compare  average  visits  per  patient  having  the  same 
diagnosis  is  it  fairly  safe  to  compare  clinics  of  different 
institutions. 

To  minimize  liability  to  error  and  to  promote 
uniformity,  the  following  recommendations  are  urged 
upon  the  consideration  of  all  Dispensaries  and  out- 
patient departments: — 

1.  In  the  Annual  Report,  print  the  list  of  clinics  in  the 
out-patient  department;  opposite  the  name  of  each  clinic 
(a)  the  number  of  new  clinic  patients;  (b)  the  total  visits;  (c) 
the  average  visits  per  patient  (i.e.  (b)  divided  by  (a)  ). 

2.  The  number  of  new  clinic  patients,  the  total  number 
of  visits,  and  the  average  visits  per  patient  for  the  institu- 
tion as  a  whole,  should  be  printed  on  the  same  page,  at  the 
foot  of  the  column  of  cUnics. 

3.  It  is  likely  to  promote  ill-founded  comparisons  between 
institutions  to  publish  the  figures  for  the  Dispensary  as  a 
whole  without  the  figures  for  the  separate  clinics;  or  to 
print  merely  the  visits  per  patient  without  giving  the  two 
figures  upon  which  this  is  based. 


EFFICIENCY  TESTS 


255 


4.  In  all  comparisons  between  different  clinics  or  different 
institutions,  when  visits  per  patient  are  utilized,  it  is  desira- 
ble to  compare  cases  of  the  same  or  similar  diagnosis. 

The  actual  work  of  making  efficiency  tests  based  on 
visits  per  patient  is  readily  illustrated  by  the  form 
below.  The  medical  record  cards  are  selected  in 
consecutive  order  or  in  any  desired  group  and  can  be 
rapidly  tallied. 


FORM  FOR  TABULATING  VISITS  PER    OUT-PATIENT,  CLASSIFIED   BY 

DIAGNOSIS 

Efficiency  Tests  in Depabtment 

for  months  of 191 


Number  of  Visits  per  Patient 

Diagnosis 

One 

Two 

Three 

Four 

Five 

Six, 
Seven, 
Eight 

Nine, 

^Ten, 

Eleven, 

Twelve 

Over 
Twelve 

Total 
Number 
of  Cases 

N.B.     The  grouping  of  Visits  into  columns  is  illustrative  merely. 
In  many  cases  it  would  be  desirable  to  have  3-5  visits  in  one  column  and  to  have 
"Over  Twelve"  sub-divided. 

Form  No.  17. 

For  purposes  of  laying  the  finger  upon  particular 
points  of  difficulty  in  a  clinic,  and  especially  in  finding 
wasted  work,  a  simple  tabulation  of  patients  who  pay 
only  one  or  two  visits  is  often  of  value.  A  large 
number  of  records  may  be  rapidly  run  through,  tally- 


256  DISPENSARIES 

ing  the  number  in  which  only  one  visit  has  been  made, 
and  in  which  only  two  have  been  made.  The  per- 
centage which  these  constitute  of  the  total  number  of 
cases  is  likely  to  be  significant.  This  is  the  quickest 
rough-and-ready  method  of  pointing  out  the  need  of 
a  follow-up  system  or  of  checking  up  the  efficiency  of 
one  already  established.  As  this  plan  requires  little 
work  in  tabulation,  it  is  a  good  beginning,  and  is  sure 
to  impress  the  medical  staff  of  a  clinic,  or  the  superin- 
tendent, with  the  proportion  of  patients  who  come 
only  once  and  fail  to  return  for  treatment  even  when 
their  diseases  clearly  require  further  visits. 

The  selection  of  records  for  the  purposes  of  these 
efficiency  tests  is  simple  when  the  medical  records  are 
kept  in  each  clinic,  filed  chronologically  in  the  order 
of  the  patients'  first  admission.  A  batch  of  records 
running  over  one  m^onth,  two  months,  six  months  or  a 
year,  may  be  picked  out  in  a  moment  and  tabulated 
on  one  of  the  above  forms  or  on  some  simplified  form, 
if  only  the  one-visit  cases  are  to  be  noted.  It  is  per- 
fectly safe  to  let  a  mere  clerk  tabulate  the  number  of 
visits  per  case  as  long  as  this  clerk  is  given  a  ruled 
tabulation  form  and  specific  instructions  for  using  it. 

Where  a  Dispensary  has  a  central  record  system  and 
tens  of  thousands  of  cases  a  year,  the  cases  of  each  clinic 
or  those  of  a  given  diagnosis  cannot  readily  be  segre- 
gated unless  there  is  a  diagnosis  index.  When  no 
diagnosis  index  exists,  the  only  way  of  studying  cases 
according  to  diagnosis  is  to  keep  a  special  index  for 
a  period  of  the  particular  diagnoses  desired.  The 
cards  used  in  the  standard  follow-up  system,  described 


EFFICIENCY  TESTS  257 

in  Chapter  XIII,  also  furnish  a  ready  Index  to  all 
the  cases  treated  in  a  clinic  during  any  specified 
period  of  time. 

Sometimes  cases  may  be  selected  without  regard  to 
clinics,  simply  taking  the  five  hundred  or  thousand 
cases  arbitrarily  and  tabulating  them  as  they  come, 
tabulating  only  certain  diagnoses  if  desired. 

Purely  statistical  '^efficiency  tests ^'  like  those  just 
described  are  necessarily  inadequate.  Much  more 
scientific  and  far-reaching  are  what  may  be  called  the 
personal  type  of  efficiency  test.  The  following  form 
has  been  found  practically  useful  and  exemplifies  the 
idea  and  method  (No.  18) : 

The  medical  records  of  a  given  diagnosis,  or  of  a 
group  of  closely  related  diagnoses,  must  be  selected. 
The  physician  who  treated  the  cases,  or  some  other 
physician,  will  then  examine  the  records  and  classify 
each  case  according  to  result  shown.  These  are  tallied 
on  the  form.  The  correlation  between  the  number  of 
visits  and  the  results  achieved  is  usually  very  sug- 
gestive. Comparison  of  different  methods  of  treat- 
ment can  be  made  in  this  way. 

The  estimation  of  medical  results  cannot  of  course 
be  made  always,  or  often,  merely  by  reading  the 
record  card.  The  outcome  of  the  case  may  be  ascer- 
tainable only  by  sending  for  the  patient  to  come  in 
for  an  examination,  or  by  sending  a  visitor  to  the 
home  to  ascertain  certain  facts,  or  by  doing  both. 
Studies  of  medical  results  necessarily  involve  time 
and  expense.  The  studies  conducted  by  Mr.  Henry 
C.  Wright,  under  the  auspices  of  a  Committee  of  the 


258 


DISPENSARIES 


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EFFICIENCY  TESTS  259 

Board  of  Estimate  of  New  York  City,  in  1913,^^  are 
examples  of  what  can  be  done  in  this  direction.  In- 
stead of  taking  a  single  clinic,  consecutive  patients 
applying  to  the  admission  desk  of  a  Dispensary  may 
be  followed  up  for  a  period,  and  the  outcome  of  a 
considerable  number  of  cases  be  tabulated.  Exam- 
ination of  the  clinical  records  may  be  supplemented 
by  house  visits. 

The  application  of  this  intensive  method  of  clinic 
or  institutional  Survey  is  limited  by  the  cost  in  time 
and  money.  Such  Surveys  will  only  be  undertaken 
when  an  institution  is  seriously  studying  itself  with 
a  view  to  self-improvement  or  reorganization;  or 
when  a  physician  or  group  of  physicians  wish  to  study 
out  the  character  and  results  of  out-patient  treatment 
of  a  particular  disease.  The  method  outlined  above 
is  adequate  for  this  purpose  and  makes  it  possible  to 
form  substantial  judgment  as  to  the  medical  possi- 
bilities in  out-patient  work. 

Efficiency  tests  in  Dispensary  service  have  thus  far 
been  utilized  chiefly  for  the  purpose  of  pointing  out 
elements  of  waste.  Tabulating  the  percentage  of 
patients  paying  only  one  or  two  visits  has  again  and 
again  led  to  stirring  up  interest  in  a  follow-up  system, 
or  for  better  organized  medical  services.  The  scien- 
tific method  for  carrying  on  efficiency  tests,  with  a 
maximum  of  value  and  a  minimum  of  expense,  would 
be  as  follows:  Each  case,  when  discharged,  or  closed 
because  of  failure  to  return,  should  be  judged  as  to 
results  and  the  judgment  entered  on  a  Sheet  for 
Closed  Cases.     The  case  is  comparatively  fresh  in 


260  DISPENSARIES 

mind  and  estimation  of  the  medical  outcome  can  be 
made  with  a  maximum  of  accuracy  and  a  minimum  of 
time  and  expense.  Any  clinic  which  has  the  follow-up 
system  described  in  Chapter  XIII  can  give  the  Med- 
ical Staff  of  the  clinic  a  continuous  self-survey  of  the 
work  they  are  doing.  They  merely  need  to  require 
that  the  medical  outcome  of  each  case  be  summarized 
(and  tallied  on  the  tally  sheet)  at  the  time  the  patient 
is  discharged,  or  at  the  time  when,  despite  the  efforts 
of  the  follow-up  system,  it  is  decided  to  drop  the  case 
because  of  failure  to  return. 

The  tally  form  for  such  cases  would  be  the  same  as 
that  shown  on  page  7.  If  desired,  only  certain  diag- 
noses might  be  followed  in  this  way. 

A  final  chart  suggests  some  points  concerning 
efficiency  tests  in  a  Dispensary: — 


EFFICIENCY  TESTS 


261 


dollarsU/efficiency)  =(Resjjlts 

BRAINS/     V  y      V  COST 

EFFICIENCY  CONUNDRUMS 


No.  1. 
If  a  tenement  house  can  kill  a  baby  as 
well  as  a  germ,  can  a  hospital  afford  to  have 
a  bacteriologist  without  a  Social    Service 
Department? 

No.  2. 

If  you  discovered  in  your  Eye  Clinic  that 
forty  per  cent  of  the  patients  who  were 
found  to  need  glasses  did  not  secure  them, 
on  what  page  of  your  Annual  Report  would 
you  publish  the  fact? 

No.  3. 

If  a  widow  with  children  to  support  needs 
a  vacation  as  well  as  Rx.  iron  or  nux  vom., 
will  you  send  her  with  your  prescription  to 
the  Social  Service  Department  or  to  the 
Apothecary? 


No.  4 
If  a  patient  with  advanced  tuberculosis  is 
sent  from  your  Medical  Clinic  back  to  his 
crowded  home  and  workshop,  how  long  do 
you  think  it  will  take  to  get  a  positive  diag- 
nosis on  one  of  his  eight  children? 


No.  5. 

If  a  discharged  cardaic  case  is  readmitted 
to  a  Hospital  six  times  within  two  years,  and 
at  the  seventh  admission  the  man  is  found 
to  have  been  living  all  the  time  five  flights 
upstairs,  will  the  Superintendent  want  a 
Social  Service  Department  to  investigate  the 
home  conditions  of  patients  and  save  th« 
$400  which  the  readmissions  cost? 


MEASURE  HOSPITAL  EFFICIENCY 


^Y 


BOTH  WAYS 


262  DISPENSARIES 


CHAPTER   XVI 
FINANCE 

The  proper  development  of  Dispensary  work  has 
been  retarded  because  insufficient  attention  has  been 
paid  to  the  cost.  A  cheap  thing  is  too  often  a  poor 
thing,  and  Dispensary  work  has  seemed  cheap. 

This  cheapness  has  been  more  apparent  than  real, 
because  of  confusion  between  the  expenses  of  the 
hospital  proper  and  of  its  out-patient  department. 
The  most  rapid  increase  in  Dispensaries  has  been 
chiefly  in  out-patient  departments.  The  Dispensary 
has  generally  utilized  rooms  already  in  the  hospital 
building.  Much  of  the  equipment  was  already  on 
hand  in  the  hospital,  and  nurses,  pupil  nurses,  house 
officers  and  medical  men  were  already  available. 
Thus  the  only  extra  expenses  for  the  Dispensary 
were  for  minor  fitting  of  rooms,  record  cards,  drugs, 
X-rays,  and  surgical  supplies.  In  the  hospital  book- 
keeping, only  these  new  and  extra  expenses  were 
charged  to  the  Dispensary;  the  work  appeared  to  cost 
little  and  to  need  little.  Such  has  been  the  typical 
beginning  of  out-patient  departments.  As  standards 
of  Dispensary  work  have  advanced,  as  more  service 
and  more  equipment  have  been  put  into  out-patient 
departments,  correspondingly  increased  attention  has 
gone  to  the  cost  accounting. 

What  is  the  cost  unit  for  Dispensary  work?     The 


FINANCE  263 

basis  for  intelligent  consideration  of  the  cost  of  any 
work  is  a  definite  unit.  In  a  hospital  this  unit  is 
understood  to  be  the  cost  per  bed  per  day;  in  a 
Dispensary  the  cost  unit  is  the  average  cost  per  visit. 
The  cost  per  patient  treated  should  only  be  figured 
when  a  special  group  of  patients,  with  a  particular 
disease  or  a  group  of  related  diseases,  is  considered 
separately.  Otherwise,  ''cost  per  patient'^  has  little 
meaning. 

In  a  report  rendered  to  the  American  Hospital 
Association,  in  1913,  by  its  Committee  on  Dispensary 
Work,  the  following  paragraphs  were  included  :^^ 

''Cost  and  cost  accounting. — Schedules  have  been  collected 
from  six  well-known  institutions,  showing  how  the  superin- 
tendent estimated  the  cost  of  the  out-patient  service  and  of 
its  various  divisions.  To  present  the  details  of  these  schedr 
ules,  would  suggest  unfair  comparisons.  The  following 
points  may  be  made: 

"  (1)  The  typical  hospital  does  not  maintain  a  considered 
segregation  of  the  expenses  of  its  out-patient  department. 
Forty  out  of  the  56  hospital  annual  reports  (71%)  previously 
referred  to  did  not  give  the  dispensary  cost  items  separable 
from  the  hospital  items. 

"(2)  A  relatively  small  number  of  hospitals  do  make  a 
careful  segregation  of  out-patient  expenses ;  but  each  has  its 
individual  system,  so  that  the  expenses  cannot  be  safely 
compared  in  detail. 

"(3)  The  average  cost  per  visit  of  an  out-patient  is  the 
best  unit  of  expense,  so  far  as  a  unit  is  desirable. 

''(4)  Costs  per  visit  vary  widely,  even  among  institu- 
tions of  high  medical  standing.  The  following  table  presents 
certain  figures  on  this  point : — 

18 


264 


DISPENSARIES 


COMPARISON  OF  AVERAGE  COST  PER  VISIT  AT  SIX  OUT- 
PATIENT DEPARTMENTS 


Hospital 
or 

Dispensary 

Visits 
Last  Year 

Expenditures 
Last  Year 

Average 

Cost  per 

Visit,  1912 

(in  Cents) 

Remarks 

A 

51,000 

69,600 

115,000 

132,000 
136,000 
236,000 

$26,600 

23,500 

55,000 

24,000 
78,200 
43,700 

62 
33.8 

47.8 

18 
57 
18.5 

A  Dispensary 

B 

not     connected 

with  a  hospital 

AnO.P.D.of 

C 

a  large  general 
hospital 

A  Dispensary 
with  a  small 
hospital 

Same  remark 

D 

E 

as  for  B 
Same  remark 

F 

as  for  B 

Same  remark 

as  for  B 

''Thus  of  these  six  institutions  giving  the  detailed  sched- 
ules referred  to,  three  spend  approximately  the  same  amount 
on  out-patient  service — $25,000  a  year.  But  the  visits  paid 
by  patients  to  these  three  are,  respectively,  51,000,  69,000 
and  132,000;  and  the  average  cost  per  visit,  therefore, 
respectively,  52  cents,  33  cents,  and  18  cents.  Institutions 
D  and  E  have  approximately  the  same  number  of  visits — a 
little  over  130,000 — paid  by  patients  during  the  year;  but 
one  of  these  two  institutions  is  spending  $24,000  in  the  year 
in  its  out-patient,  and  the  other  $78,000,  the  average  cost  per 
visit  being,  therefore,  18  cents  and  57  cents. 

''(5)  Differences  in  average  cost  per  out-patient  visit  are 
due  partly  to  differences  in  organization,  character  of  equip- 
ment, extent  of  medical  teaching,  etc.;  partly  to  actual  dif- 
ferences in  standards  of  efficiency;  and,  finally,  are  partly 
factitious,  owing  to  different  methods  of  accounting. 


FINANCE  265 

/'  (6)  Although  for  these  reasons  comparisons  of  average 
cost  per  visit  must  be  made  with  great  caution  when  different 
institutions  are  compared,  this  cost  unit  is  of  the  utmost 
value  to  every  Dispensary  and  out-patient  department  in 
the  annual  study  of  the  progress  of  its  own  work.  The 
greatest  value  of  keeping  good  Dispensary  accounts  is  in 
self-criticism  rather  than  in  comparison. 

''(7)  What  shall  we  do  about  this  matter  of  cost?  If 
accurate  and  uniform  cost  figures  for  hospitals  are  stiU 
difficult  to  get,  must  not  accurate  and  uniform  out-patient 
figures  be  inconceivable?  The  inconceivable,  however, 
happens  when  it  becomes  necessary.  With  the  rapid  growth 
of  out-patient  work  and  its  assumption  by  municipal  and 
state  authorities,  segregated  Dispensary  accounting  is  a  near 
necessity." 

The  advance  in  Dispensary  work  is  illustrated  by 
changes  which  have  taken  place  since  1913,  when  the 
above  table  was  prepared.  Even  before  the  higher 
cost  of  supplies,  due  to  the  War,  had  affected  institu- 
tions much,  most  items  in  column  4  had  risen  to  a 
material  degree.  Institution  A  was  an  exception. 
B  undertook  a  notable  development  in  its  out-patient 
department,  raising  its  cost  to  53.7  cents  (1915)  as 
compared  with  33.8  cents.  The  figure  for  D  rose  to 
about  23  cents;*  for  E,  to  about  59  cents,  and  for  F 
to  about  25  cents.*  All  these  institutions  had  good 
cost  accounting  systems  to  start  with,  the  increase  in 
cost  being  chiefly  due  to  an  elevation  in  standard. 

*  "D'*  had  no  definitely  organized  admission  department;  no  social 
service;  no  clinical  clerks;  its  standard  of  service  was  materially  lower 
than  any  of  the  others.  "F"  maintained  two  complete  sets  of  daily 
clinics,  one  in  morning,  one  in  afternoon,  thus  utilizing  plant  and  much 
employed  staff  twice  and  materially  reducing  fixed  charges. 


266  DISPENSARIES 

The  Dispensaries  above  mentioned  may  be  contrasted 
with  two  large  Dispensaries  in  New  York  City,  which 
were  referred  to  in  the  1914  report  of  the  Committee  on 
Dispensary  Work  of  the  American  Hospital  Associa- 
tion, as  follows: 

''We  might  consider  two  large  Dispensaries,  one  of  which 
reports  a  cost  per  visit  of  26  cents,  the  other  of  15  cents. 
Both  these  Dispensaries,  however,  give  salaries  to  their 
medical  staff,  so  they  cannot  be  compared  with  the  majority 
of  Dispensaries  which  do  not  pay  medical  salaries.  Deduct- 
ing the  amount  paid  in  medical  salaries,  the  cost  per  visit 
of  these  two  institutions  reduces,  respectively,  to  18  cents 
and  7  cents,  these  being  among  the  very  largest  Dispensaries, 
separate  from  hospitals,  which  exist  in  the  United  States. 
Further  comparison  shows  that  the  difference  between  18 
cents  and  7  cents  is  largely  due  to  the  fact  that  one  of  the 
institutions  has  a  social  service  department,  and  the  other 
has  not,  this  department  adding  several  thousand  dollars 
annually  to  the  salary  budget.  Other  detailed  comparisons 
could  be  made." 

Both  these  Dispensaries  were  apparently  suffering 
severely  from  overcrowding  of  clinics  and  also  from 
inadequate  funds  for  salaried  assistance  and  (in  less 
degree)  for  equipment. 

After  a  study  of  the  standard  of  work  in  all  these 
institutions,  comparing  carefully  the  various  types, 
there  is  reason  to  believe  that  a  standard  of  50  cents 
per  visit  is  not  too  low,  without  including  any  salaries 
to  clinical  physicians. 

In  a  Dispensary  unconnected  with  a  hospital,  the 
charges  for  the  maintenance  of  the  plant  will  be  higher 


FINANCE  267 

than  where  a  similar  building  is  part  of  a  large  hospital. 
In  the  latter  case  the  element  of  supervision,  the  cor- 
poration expenses  and  other  overhead  charges,  are  also 
proportionately  reduced.  Otherwise,  the  expenses  for 
operating  a  large  Dispensary  separate  from  a  hospital 
are  substantially  the  same  as  those  of  an  out-patient 
department  of  a  hospital.  The  services  rendered  in 
the  Dispensary,  by  nurses  and  other  salaried  persons 
on  the  hospital  staff,  must  of  course  be  charged  to 
the  out-patient  department;  likewise  a  proportionate 
share  of  the  maintenance  of  internes,  pupil  nurses, 
cleaners,  etc.,  who  are  boarded  by  the  hospital  and 
give  part  time  to  the  Dispensary.  All  things  con- 
sidered, the  preceding  table,  as  well  as  detailed  study 
of  the  operation  of  many  Dispensaries,  indicates  that 
the  cost  of  operating  a  well-equipped  and  suitably 
organized  Dispensary,  whether  an  out-patient  de- 
partment of  a  hospital  or  independent  of  a  hospital, 
may  well  be  about  50  cents  per  visit.  Salaries  to  visit- 
ing medical  staff,  except  in  the  Laboratory,  X-ray, 
and  Dental  departments,  are  not  included  herein. 

The  cost  per  visit  at  a  Dispensary  depends  on  two 
factors:  first,  the  expenditure;  second,  the  number  of 
visits.  Now  the  number  of  visits  is  highly  flexible, 
even  more  so  than  the  expenses.  If  too  little  money 
is  spent,  the  proper  standard  of  Dispensary  work  can- 
not be  maintained;  on  the  other  hand,  with  a  given 
building  and  organization,  if  too  many  patients  are 
admitted  in  proportion  to  these  facilities,  the  standard 
of  work  must  fall  below  the  proper  level.  Proper  cost 
accounting  and  a  definite  standard  of  work  must  be 


268  DISPENSARIES 

chiefly  depended  on  to  check  the  great  vice  of  Dispen- 
saries, i.e.,  overcrowding. 

It  may  be  pointed  out  that  not  a  few  institutions 
known  the  country  over  for  their  medical  work  report 
that  their  out-patient  departments  cost  25  cents  to  30 
cents  per  visit.  This  is  true.  But  these  instances 
are  getting  fewer  every  year.  Their  Dispensary  cost 
accounting  also  needs  to  be  looked  into,  before  their 
figure  of  cost  per  visit  is  accepted.  Standard  of  service 
should  then  be  examined. 

Assuming  that  50  cents  per  visit  is  correct,  let  us  so 
far  as  possible  sub-divide  this  into  elements.  This 
can  be  done  only  roughly;  the  divisions  made  are  for 
purposes  of  practical  convenience  and  do  not  follow  a 
theoretical  classification. 

Roughly,  the  50  cents  may  be  divided  into  half  for 
salaries  and  half  for  non-salary  accounts.  Of  the  25 
cents  for  salaries  we  may  charge  three  cents  to  five 
cents  for  supervision;  the  remainder  to  salaried 
services.  Nurses,  attendants  and  clerks  would  take 
about  seven  to  nine  cents;  social  service  ten  cents,  and 
laboratory  and  X-ray  salaries  three  to  five  cents. 

Of  the  supply  accounts,  maintenance  of  building 
and  laundry  (including  salaries  and  supplies  together) , 
would  include  about  eight  cents;  general  medical  and 
surgical  supplies  eight  to  ten  cents,  and  pharmacy, 
including  salaries  and  drugs  and  chemicals,  ten  cents. 

These  rough  divisions  are  merely  suggestive,  but 
will  illustrate  a  very  important  point.  Certain 
elements  in  cost  vary  closely  according  to  the  number 
of  visits  paid,  others  but  slightly.     The  drugs  and 


FINANCE  269 

medical  and  surgical  supplies  used  vary  in  rough 
proportion  to  the  number  of  visits  paid,  while  the 
maintenance  of  plant  and  the  supervision  are  almost 
constant  factors.  The  amount  of  nursing  and  social 
service  required  varies  with  the  number  of  visits,  but 
not  in  any  direct  proportion.  That  is,  a  considerable 
increase  in  the  number  of  visits  might  take  place  with- 
out requiring  the  actual  addition  of  new  persons  to  the 
salaried  staff. 

In  other  words,  the  proportion  of  relatively  fixed 
charges  in  dispensary  work  is  quite  large  in  comparison 
with  the  charges  that  vary  closely  in  proportion  to  the 
number  of  visits.  Only  about  twenty-five  per  cent  to 
thirty-five  per  cent  of  the  cost  of  running  a  Dispen- 
sary varies  closely  with  the  number  of  visits.  About 
fifty  per  cent  of  the  cost  varies  slightly  according  to 
number  of  visits  and  the  remainder  fifteen  per  cent  to 
twenty-five  per  cent  is  substantially  a  fixed  charge. 

If  we  compare  this  with  hospital  beds,  we  will  see  at 
once  that  the  proportion  of  the  variable  charges  in 
connection  with  hospital  beds  is  much  higher. 

The  effect  of  this  small  proportion  of  variable  charge 
as  compared  with  total  charge  in  Dispensary  work  is  to 
encourage  that  chief  abuse  of  the  Dispensary,  over- 
crowding. An  increased  number  of  visits  from  pa- 
tients does  not  show  largely  in  the  cost  account;  it  does 
look  well  in  the  Annual  Report. 

If  the  medical  staff  in  a  Dispensary  is  salaried,  how 
would  this  affect  cost?  There  is  but  little  definite 
information  on  this  point  as  yet,  and  what  can  be  said 
here  is  largely  estimate.     The  Mayo  Clinic  in  Roches- 


270  DISPENSARIES 

ter,  Minnesota,  and  a  few  pay  clinics  at  the  Boston 
Dispensary  and  elsewhere,  furnish  a  few  facts;  like- 
wise some  of  the  large  Dispensaries  in  New  York 
City.  Tentatively  it  may  be  said  that  paying  the 
staff  sufficient  amounts  to  be  called  a  moderate 
economic  compensation  for  the  service  rendered, 
would  about  double  the  cost  of  the  clinics;  that  is, 
would  average  50  cents  a  visit.*  The  salaries  on 
which  this  estimate  is  computed  will  vary  of  course 
with  the  rank  of  the  physician  or  surgeon  in  the  clinic, 
and  to  a  certain  extent  with  the  character  of  the  work, 
the  actual  remuneration  rates  of  a  clinic  lasting  two 
hours  being  at  the  rate  of  from  $10  to  $2.50.  It  must 
be  borne  in  mind  that  in  the  doctor's  private  office  all 
the  expenses  of  rent,  equipment  and  assistance  are 
paid  by  the  doctor  and  must  come  out  of  the  fee  he 
receives  from  the  patient.  In  the  Dispensary  all  these 
are  provided  by  the  institution  and  whatever  the 
doctor  receives  is  net.  Further  discussion  of  this  will 
appear  in  connection  with  the  Pay  Clinic. 

How  shall  the  general  hospital  keep  the  cost  of  its 
Out-Patient  Department  separate  without  undue 
labor?  The  following  paragraph,  quoted  from  the 
1915  Report  of  the  Presbyterian  Hospital  of  New  York, 
outlines  an  excellent  and  accepted  form  of  statement. 
There  is  no  more  difficulty  in  separating  the  costs  of 
the  Out-Patient  Department  than  of  any  other  branch 
of  the  hospital  service.  A  hospital  which  has  no 
adequate  cost  accounting  at  all,  of  course  has  no 

*  The  average  cost  per  visit,  therefore,  in  such  a  pay  clinic,  would  be 
about  $1.00. 


FINANCE  271 

Dispensary  cost  accounts.  A  hospital  which  has  a 
satisfactory  cost  accounting  system  need  not  fear  that 
adequate  separation  of  Dispensary  charges  will  mean 
undue  bookkeeping.  The  problem  is  mainly  one  of 
initial  analysis,  i.e.,  of  deciding  what  are  the  elements 
in  the  Dispensary  cost  which  need  to  be  segregated. 
That  decision  reached,  the  slight  extra  bookkeeping 
will  be  more  than  counterbalanced  by  savings  due  to 
closer  watching  of  Dispensary  expenses,  which  the 
segregated  accounts  will  facilitate. 

"Method  of  Figuring  Cost  of  Different  Branches  of  the 
Service :  The  method  in  use  at  the  Presbyterian  Hospital  of 
figuring  the  total  cost  of  caring  for  Ward  Patients,  Private 
Room  Patients,  Out-Patient  Department  Patients,  or 
patients  visited  in  their  homes,  is  to  charge  each  branch  of 
the  service  with  salaries  and  wages  of  all  persons  employed 
exclusively  in,  and  all  supplies  and  repairs  directly  charge- 
able to  such  service,  and  to  pro-rate  the  other  operating 
expenses  which  contribute  to  the  cost  of  the  different 
branches  of  service  in  such  proportion  as  the  Superintendent 
and  his  Assistants  may  consider  most  fair  after  careful  con- 
sideration of  the  local  conditions,  which  are,  of  course,  sub- 
ject to  change  from  time  to  time.  In  determining  the  rela- 
tive proportion  of  Administration  Expenses,  Professional 
Care  of  Patients,  Housekeeping,  Kitchen,  etc.,  not  includ- 
ing the  amounts  directly  chargeable  to  Out-Patient  Depart- 
ment and  Visiting  Nursing,  the  percentage  charged  to 
Ward  Patients  and  to  Private  Room  Patients  is  based  upon 
the  number  of  days'  treatment  furnished  in  each  service; 
modified  by  well  known  facts;  for  instance,  the  fact  that  a 
private  room  patient  requires  more  professional  care  than 
necessary  if  he  were  located  in  a  ward;  also,  the  important 


272  DISPENSARIES 

fact  that  his  food  and  the  preparation  of  it  costs  very  much 
more  than  that  of  the  ward  patient.  The  distribution  of 
the  cost  of  General  House  and  Property  Expenses  among  the 
different  branches  of  the  service  is  based  upon  the  relative 
cubic  contents  of  those  parts  of  the  buildings  occupied  by 
each  of  the  five  services  mentioned. "^^ 

The  above  statement  of  the  Presbyterian  Hospital 
gives  the  main  items  which  should  enter  into  the  Dis- 
pensary cost  account.  To  this  list  should  be  added 
Medical  Salaries  for  clinical  physicians,  if  such  salaries 
are  paid.  As  previously  noted,  the  salaries  of  persons 
employed  by  the  hospital  should  be  charged  to  the 
Out-Patient  Department  in  proportion  to  the  time 
given  by  them  to  the  latter.  A  due  share  of  the  board 
of  internes,  nurses,  servants,  etc.,  should  be  charged 
likewise  if  they  work  in  the  Dispensary.  This  item 
theoretically  belongs  under  salaries,  though  more 
readily  charged  under  housekeeping.  General  over- 
head charges  for  administration  and  supervision,  cor- 
poration expenses,  etc.,  may  be  charged  to  the  Out- 
Patient  Department  at  a  fixed  percentage,  estimated 
as  proper  by  the  superintendent.  Heating  and  light- 
ing may  be  charged  similarly  by  a  percentage,  esti- 
mated as  the  probable  share  of  the  out-patient  build- 
ing. These  merely  follow  the  general  principles  of 
cost  accounting  applicable  to  any  branch  of  an  institu- 
tion. 

A  Dispensary  separate  from  a  hospital  may  wisely 
use  the  same  scheme  of  classifying  expenses,  but  will 
of  course  be  saved  the  labor  of  segregating  dispensary 
from  hospital  accounts. 


FINANCE  273 

The  administrative  records  needed  in  keeping  track 
of  the  expenses  in  a  Dispensary  are  similar  to  those 
useful  in  a  hospital,  so  far  as  requisitions  for  supplies, 
purchasing  orders,  stock  cards,  pay-roll  sheets,  etc., 
are  concerned.  Where  fees  are  charged  for  admission, 
treatment,  medicines,  operations  or  supplies,  provision 
must  be  made  for  proper  checking  and  reporting  of 
receipts.  The  clinic  slips  described  on  page  196, 
used  at  the  cashier's  desk,  furnish  a  sufficient  check. 
The  bookkeeper  should  have  a  Fee  Receipt  Book  for  the 
Dispensary  (or  loose  leaves  capable  of  being  bound). 
Each  day  she  should  enter  the  receipts  from  each 
clinic,  or  each  item  which  it  is  desired  to  follow,  as 
eye-glasses  or  medicines.  These  can  be  totaled 
monthly.  A  large  sheet  ruled  with  a  column  for  each 
clinic  or  item,  and  providing  a  line  for  each  day,  may 
be  totalled  at  the  end  of  the  month  and  serve  as  a 
permanent  record.  Fees  remitted  (see  below)  should 
be  entered  on  the  same  sheet. 

In  the  preceding  discussion  of  costs,  the  Dispensary 
has  been  viewed  as  a  whole.  When  the  different 
clinics,  however,  are  studied  separately,  they  will  be 
found  to  vary  widely  in  cost.  It  is  entirely  practicable 
to  keep  a  cost  account  for  each  clinic.  The  salaries, 
or  share  of  salary  (or  board)  of  each  person  working 
in  the  clinic,  are  charged  thereto.  The  supplies  used 
in  each  clinic  are  kept  track  of  by  charging  from  the 
requisitions  made  by  the  clinic. 

The  superintendent  of  an  institution  is  interested  in 
cost,  but  often  most  of  all  in  the  practical  question: 
How  shall  the  cost  be  met?    Elsewhere  has  been  de- 


274  DISPENSARIES 

scribed  the  fee  systems  common  in  Dispensaries. 
From  comparative  study  of  many  charitable  and  teach- 
ing Dispensaries,  it  has  been  found  that  from  twenty- 
five  per  cent  to  sixty-six  and  two-thirds  per  cent  of  the 
cost  has  been  met  in  this  way.  It  is  safe  to  say  that 
as  much  as  fifty  per  cent  of  the  total  expense  can  be 
reasonably  expected  to  come  back. 

In  institutions  founded  for  the  public  welfare  or  for 
''charity, "  there  must  be  a  clear  understanding  that  no 
patient  is  to  be  refused  treatment  for  lack  of  money, 
unless  arrangements  for  treatment  elsewhere  are  act- 
ually made  before  the  patient  is  lost  sight  of.  Fees 
must  therefore  be  remitted  when  necessary  and  definite 
responsibility  for  making  remissions  must  be  placed 
somewhere.  In  Chapter  XII  it  is  advised  that  the 
Admission  Department  (in  practice,  the  chief  ad- 
mitting officer)  should  have  this  responsibility.  The 
recommendation  of  the  Social  Service  Department 
concerning  any  case  will  ordinarily  have  determining 
weight,  if  based,  as  it  usually  will  be,  upon  contact 
with  the  family  conditions.  For  the  ordinary  ad- 
mission or  medicine,  where  the  fee  is  10  cents  or  25 
cents,  home  investigation,  merely  for  the  purpose  of 
deciding  as  to  remission,  is  not  to  be  thought  of.  The 
average  cost  of  such  an  investigation  would  be  over 
50  cents.  The  great  majority  of  patients  who  say  at 
the  admission  desk  that  they  cannot  pay  the  fee, 
either  have  not  the  money  with  them,  or  else  have  not 
money  anywhere,  enough  to  justify  payment  of  a  fee. 
In  either  case  they  must  be  passed  on,  unless  an  at- 
tempt to  impose  is  definitely  suspected.     This  is  rare. 


FINANCE  275 

Home  investigation  of  sample  groups  of  cases  has  in- 
dicated that  while  of  course  there  are  occasional  in- 
stances of  imposition,  the  percentage  is  very  small. 
When  a  patient  says  ^'I  haven't  the  money  with  me," 
he  may  be  asked  to  bring  it  at  the  next  visit.  A  sur- 
prising number  will  do  so. 

What  fees  should  be  levied  for  the  various  services 
and  supplies  furnished  in  a  Dispensary?  In  a  number 
of  representative  institutions,  in  1917,  the  admission 
fees  ranged  between  25  cents  and  10  cents  per  visit. 
A  few  Dispensaries  have  tried  a  system  of  graded 
admission  fees,  patients  being  divided  into  classes  at 
the  first  visit,  and  given  admission  cards  of  different 
colors,  corresponding  to  rates  of  50  cents,  25  cents, 
10  cents  and  free.  But  no  satisfactory  solution  of 
difficulties  involved  in  this  plan  has  yet  been  achieved. 
Not  infrequently  children  are  charged  less  than  adults,  » 
and  the  first  visit  often  has  a  higher  fee  than  the  sue-  \ 
ceeding  ones.  Some  clinics  which  do  not  charge  admis- 
sion fees  make  charges  for  dressings  and  for  medicines. 
Most  clinics  which  levy  admission  fees  charge  for 
medicines  in  addition,  but  not  usually  for  dressings 
or  bandages,  unless  these  are  unusually  expensive. 
Rates  for  X-rays  range  from  50  cents  to  $1.00,  and 
usually  more  for  bismuth  work.  Laboratory  tests 
are  usually  free,  except  sometimes  the  serological 
work.  Wassermann  tests,  when  not  free,  are  usually  \ 
priced  at  from  25  cents  to  $1.00.  Operations  under 
anaesthesia  are  often  charged  for,  at  fees  of  from  50 
cents  to  $2.50  (of  course  more  if  over-night  hospital 
care  is  included).     In  fixing  fees  for  medicines,  dental 


276  DISPENSARIES 

materials,  surgical  appliances,  and  other  supplies, 
the  cost  of  materials  is  the  usual  basis,  but  to  this 
should  be  added  an  allowance  for  the  expense  of 
compounding  the  prescriptions,  or  making  up  the 
bandages,  etc.,  if  the  actual  cost  is  to  be  covered.  A 
percentage  is  sometimes  added  to  this ;  but  in  the  case 
of  expensive  services,  such  as  X-rays,  the  cost  is  much 
too  high  for  the  average  patient  to  meet,  and  lower 
than  cost  rate  must  be  charged.  For  medicines  it  is 
generally  best  to  have  a  few  rates  into  which  most 
prescriptions  fall — e.g.,  10  cents,  20  cents,  30  cents; 
with  unusually  expensive  drugs  priced  at  other  rates. 
Generally  speaking,  it  is  undesirable  to  have  a  fee  rate 
so  high  that  the  fee  has  to  be  remitted,  in  whole  or 
part,  in  more  than  half  the  cases.  It  is  better  to  make 
a  lower  rate  and  not  allow  the  percentage  of  remissions 
to  rise  above  ten  per  cent  or  fifteen  per  cent.  In  the 
case  of  X-rays,  however,  where  the  fee  is  50  cents, 
$1.00  or  more,  the  remission  percentage  will  often  be 
much  higher,  as  much  as  fifty  per  cent. 

For  all  fees  above  25  cents,  for  which  a  material 
equivalent  is  given,  as  in  the  case  of  eye-glasses,  braces, 
dental  plates,  etc.,  payment  by  installment  should  be 
allowed.  This  may  best  be  administered  by  the  Social 
Service  Department.  A  card  record  can  be  made  for 
each  case,  according  to  such  a  form  as  is  shown  here- 
with. The  particular  social  worker  who  is  in  touch 
with  the  patient  should  receive  the  installments.  If  it 
is  done  in  this  personal  way,  a  much  larger  percentage 
will  be  collected  than  at  a  cashier's  office.  At  two 
institutions  from  which  facts  have  been  collected,  the 


5000—5-16 
Date 

FINANCE                                 277 

Worker 

Rx.  No. 

Name 

Record  Number 

S.  S.  Number 

Article 

Price  to 
Price  to  Disp.                Patient 

To  be  paid  by  Patient 

To  be  paid  by  Social  Agency 

Date 

Amomit 

Name  of  Agency 

Date  of  Payment 

Remarks : 

Form  19. 

losses  are  extremely  small,  not  over  two  per  cent.  On 
articles  costing  from  $2.00  to  $10.00  the  usual  in- 
stallment rate  is  from  25  cents  to  50  cents  per  week. 

The  oflScial,  or  Board,  who  is  responsible  for  financ- 
ing a  Dispensary  must  usually  secure  income  from 
other  sources  than  fees.  These  must  ordinarily  be: 
(1)  endowment,  (2)  municipal  or  state  appropria- 
tions, (3)  philanthropic  contributions. 

Appropriations  and  contributions  are  alike  in  one 
respect,  namely,  that  some  one  has  to  be  convinced 
that  the  Dispensary's  work  is  worth  while.  The 
Superintendent,  the  Medical  Staff,  and  the  Board  of 
Trustees,  need  first  of  all  to  be  assured  of  this  them- 
selves. If  they  are  so  assured,  and  really  care,  they 
are  likely  to  prove  convincing  either  to  a  city  council 
or  to  the  charitable  public.     A   Dispensary's  work 


278  DISPENSARIES 

contains  many  elements  of  appeal.  It  deals  with 
many  concrete  things;  people,  often  very  obviously 
needy  people,  such  as  sick  babies  and  cripples;  it 
provides  definite  forms  of  service  which  any  one  can 
understand.  It  is  an  interesting  place  for  a  layman  to 
visit.  Its  results  can  be  measured,  at  least  roughly, 
and  its  bulk  of  work  can  be  quantitatively  expressed. 

To  make  these  potentialities  effective  in  securing 
financial  support,  requires  chiefly  somebody's  imagina- 
tion. The  Annual  Report  is  the  usual  and  main 
publication  of  a  Dispensary.  For  an  Out-Patient 
Department,  the  Report  is  usually  part  of  the  larger 
pamphlet  issued  for  the  Hospital  as  a  whole.  In  the 
report  of  the  Committee  on  Dispensary  Work  of  the 
American  Hospital  Association  in  1913,  appeared  the 
following  paragraphs  on  this  topic: — ^^ 

''Fifty-six  annual  reports  of  well-known  hospitals  have 
been  examined  to  see  what  they  said  about  their  out-pa- 
tient work.*  The  out-patient  departments  of  these  56 
hospitals  had  under  treatment  last  year  over  a  million 
persons;  yet  three-quarters  of  the  annual  reports  made 

*  "As  to  out-patient  statistics,  all  the  hospitals  except  one  mention  the 
number  of  patients  treated,  and  all  except  two  give  also  the  number  of 
visits  paid  by  these  patients.  Nearly  one-third  (17  out  of  55)  of  these 
hospitals,  however,  give  only  the  total  number  of  patients  and  visits, 
and  do  not  divide  them  according  to  the  different  clinical  departments. 
If  one  examines  a  number  of  hospital  reports,  one  is  also  forced  to  note 
with  pain  that  seventy-three  per  cent  of  them  (42  out  of  56)  have  no 
index  or  table  of  contents,  so  that  it  is  necessary  to  hunt  through  a  report 
of  from  40  to  150  pages  to  find  anything  in  it  that  one  ia  looking  for, 
such  as  out-patient  statistics. 

"All  the  hospital  reports  give  the  list  of  their  medical  staff,  usually, 
though  not  invariably,  classified  under  chnical  departments.  The 
diseases  treated  in  the  out-patient  clinic  were  presented  in  a  surprisingly 


FINANCE  279 

absolutely  no  mention  of  the  fact  that  the  hospital  has  an 
out-patient  department,  except  such  indication  as  is  to  be 
found  in  a  brief  statistical  table  of  patients  and  visits. 

"A  very  well-known  hospital  in  one  of  our  largest  cities 
issues  a  handsome  report  of  160  pages.  The  medical  wards, 
the  surgical,  orthopedic,  maternity,  gynaecological,  eye, 
children's  and  neurological  wards  have  each  an  'Auxiliary 
Committee,'  and  each  Auxiliary  Committee  presents  a  re- 
port of  its  special  work,  needs  and  financial  supporters. 
Altogether  these  wards  treated  over  4,500  patients  last  year. 
The  out-patient  department  of  this  hospital  treated  just 
about  three  times  as  many;  but  the  out-patient  department 
has  no  Auxiliary  Committee;  it  has  no  special  report;  and, 
except  for  the  statistical  tables,  one  would  only  know  that 
the  hospital  had  an  out-patient  department  from  two  sen- 
tences in  the  report  of  the  President  of  the  Board  of  Trustees 
to  the  effect  that  the  Dispensary  service  has  been  improved, 
that  Social  Service  has  been  established,  and  that  the  pa- 
tients in  the  Dispensary  have  been  supplied  with  individual 
drinking  cups ! 

''The  report  of  this  Board  of  Trustees  is  exceptional  in 
one  respect,  namely,  that  the  Dispensary  is  mentioned  at 
all!     Only  eight  hospitals  out  of  the  56  had  any  special 

large  number  of  cases,  considering  the  relatively  small  value  of  the  in- 
formation thus  conveyed.  Twenty-three  out  of  56  hospitals  published 
a  more  or  less  extensive  list  of  diseases  treated,  usually  with  the  number 
of  cases  of  each  disease. 

"The  reports  of  finances  are  of  great  negative  interest.  Thus  out  of 
56  hospital  reports: 

"Seven  gave  no  financial  statement  of  any  kind; 

"Thirty-three  presented  a  financial  statement,  but  not  classified  in 
such  a  way  that  the  expenses  of  the  out-patient  department  were  either 
given  or  ascertainable; 

"Sixteen  presented  a  financial  statement  so  itemized  that  the  expenses 
of  the  out-patient  department  were  separated. " 

19 


280  DISPENSARIES 

report  for  the  out-patient  department  in  their  annual  re- 
port ;  and  in  three  of  these  eight  cases  the  report  was  merely 
a  formal  presentation  of  figures.  There  were  also  four 
hospitals  which  gave  a  little  space  to  discussing  the  problems 
of  the  out-patient  department,  but  did  not  dignify  it  by  any 
special  page  or  heading.  Thus  only  fifteen  per  cent  (nine 
out  of  fifty-six)  said  anything  about  their  out-patient  depart- 
ment. Can  it  be  true  that  an  out-patient  department  may 
treat  1,000  or  20,000  human  beings  in  a  year  and  not  have 
any  problems  or  any  needs? 

''Without  entering  further  into  the  details  gathered  from 
these  annual  reports,  enough  has  been  said  to  show  the  small 
number  of  crumbs  which  the  average  hospital  management 
throws  to  this  poor  relation  at  the  hospital  table.  How 
can  hospitals  expect  to  get  funds  to  improve  out-patient 
work  so  long  as  they  hide  its  light  under  a  bushel?'' 

An  examination  of  the  Reports  of  the  same  institu- 
tions for  1917  would  show  some  progress  in  respect  to 
the  position  given  the  Out-Patient  Department. 
Paragraphs,  pages  and  sections  devoted  thereto  are 
much  more  common,  and  statistics  are  better  pre- 
sented. The  faults  of  Annual  Reports  with  regard  to 
the  Out-Patient  Department  are  the  same  faults  as 
those  which  appear  with  respect  to  the  Report  of  the 
Hospital  as  a  whole.  Trustees  and  Superintendents 
are  not  necessarily  literary  men  or  publicity  agents, 
but  an  Annual  Report,  if  it  is  really  to  impress  the 
local  public,  must  be  prepared  by,  or  with  the  advice 
of,  people  who  are  a  little  of  both.  The  subject  matter 
should  be  so  presented  as  to  bring  out  features  of 
human  interest  as  well  as  all  elements  of  service  to  the 
community;  the  arrangement  should  be  such  as  will 


FINANCE  281 

make  the  interesting  parts  most  accessible,  and  as- 
sign tables  of  statistics,  lists  of  names,  etc.,  to  less 
prominent  sections.  Pictures  and  charts  are  useful, 
but  realize  only  half  their  potential  value  unless  they 
illustrate  the  text  instead  of  merely  accompanying  it. 

In  the  large  city  are  plenty  of  literary,  journalistic 
and  advertising  men  who  know  how  to  say  and  ar- 
range things  effectively,  and  who  would  volunteer  aid 
if  interested  through  some  friend  among  the  Trustees. 
In  smaller  places  the  supply  of  expert  publicity  men  is 
less  plentiful.  But  in  most  towns  large  enough  to  have 
a  hospital  there  is  a  local  newspaper  whose  editor  can 
and  probably  will  be  glad  to  help. 

The  Out-Patient  Department  has  in  it  elements  of 
appeal,  as  already  pointed  out,  which  should  make  it  a 
source  of  strength  for  the  hospital  which  goes  before 
the  general  public  for  subscriptions.  The  routinists 
who  do  not  see  or  cannot  present  the  hospital's  work 
to  their  community  in  an  interesting  and  convincing 
manner,  are  likely  to  receive  the  amount  of  support 
which  they  deserve.  Above  all,  those  who  can  tell  not 
only  of  the  work,  but  of  its  needs  and  its  program,  are 
likely  to  command  and  hold  an  intelligent  public. 
An  ^'efficiency  conundrum '^  displayed  at  the  American 
Hospital  Association  in  1914  puts  this  in  a  nutshell: — 

''Q.  When  is  a  Dispensary  for  the  Poor  a  poor  Dispen- 
sary? 

''A.  When  it  hasn't  enough  money  to  provide  efficient 
treatment  for  its  patients,  nor  enough  imagination  to  pre- 
pare a  program  which  will  convince  the  public  of  its  needs.  '* 


282  DISPENSARIES 


CHAPTER   XVII 

THE  OUT-PATIENT  DEPARTMENT  OF  THE  SMALL 

HOSPITAL 

There  are  four  reasons  why  an  out-patient  depart- 
ment is  desirable  in  connection  with  any  hospital: — 

1.  Benefits  to  the  needy  of  the  district. 

2.  Benefits  to  the  health  of  the  community  as  a  whole. 

3.  Benefits  to  the  local  medical  profession  through  in- 
crease of  diagnostic  and  therapeutic  facilities. 

4.  Increased  efficiency  and  economy  in  the  ward  work  of 
the  hospital  itself .^^ 

The  value  of  an  out-patient  department  to  the 
hospital  itself  has  been  discussed  in  earlier  chapters 
but  may  be  again  illustrated  by  the  following  chart  :* — 

There  are  often  found  hospitals  of  from  25  to  200 
beds,  doing  mostly  work  for  private  patients,  and  only 
a  relatively  small  amount  of  ''charity  work. "  If  such 
a  hospital  is  located  in  a  large  city,  where  there  are 
large  out-patient  departments  in  the  vicinity,  it  is 
perhaps  a  question  whether  a  new,  small  out-patient 
department  would  be  justifiied.  Probably  the  only 
ground  for  favoring  it,  in  such  a  case,  would  be  the 
fourth  of  the  above  reasons.  Such  an  out-patient 
department  would,  if  properly  managed,  improve  the 
ward  work  by  promoting  good  after-care,  prompter 

♦Reproduced  from  an  article  by  one  of  the  authors  in  The  Modern 
Hospital. 


SMALL  OUT-PATIENT   DEPARTMENT      283 


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284  DISPENSARIES 

discharge  and  more  thorough  cure  of  patients.  When 
hospitals  of  this  type  are  located  in  a  large  city,  how- 
ever, it  is  probably  better  that  they  confine  their  at- 
tention to  private  work  entirely,  and  that  they  do  not 
undertake  ^'ward"  or  ''charity"  work  at  all,  unless 
they  undertake  enough  of  it  to  make  more  than  a 
show  in  the  Annual  Report. 

Certain  hospitals  have  established  out-patient  de- 
partments entirely  for  work  on  their  own  discharged 
cases,  even  when  these  cases  are  private  patients  of 
local  physicians.  Such  out-patient  clinics,  mostly  for 
surgical  dressings,  are  referred  to  in  connection  with 
Pay  Clinics.  This  chapter,  however,  will  deal  chiefly 
with  the  hospital  in  the  community  of  moderate  or 
small  size.  Such  a  hospital  may  be  the  only  one  in  the 
town,  or  there  may  be  one  or  two  others.  Unusual 
local  conditions  aside,  it  may  be  laid  down  as  a  general 
rule  that  a  hospital  of  this  type  needs  an  out-patient 
department  for  its  own  sake,  and  that  the  community 
needs  one  very  much  indeed.  All  that  has  been  said 
of  the  functions  of  a  Dispensary,  and  of  the  difficulty 
with  which  skilled  medical  service  can  be  secured  in 
adequate  extent  by  the  mass  of  the  people,  will  be 
sufficient  to  indicate  the  foundation  of  the  first  two 
of  the  four  ''reasons"  stated  at  the  opening  of  this 
chapter. 

There  are  some  communities  which  proudly  insist 
that  they  "have  no  poor. "  That  is  not  so  remarkable 
as  it  sounds,  even  in  America.  As  a  matter  of  fact 
the  real  question  is  not  whether  there  are  "poor" 
people  in  the  community,  but  whether  there  are  people 


SMALL  aUT-PATIENT   DEPARTMENT      285 

who  cannot  afford  enough  medical  service  when  they 
need  it,  particularly  in  the  specialties.  The  superin- 
tendent and  trustees  of  the  hospital  in  the  small  city 
must  not  think  of  medical  service  on  the  basis  of  acute 
or  serious  illness  only.  Any  physician  will  follow  the 
splendid  traditions  of  the  medical  profession  and  an- 
swer a  call  to  the  bed  of  one  who  is  critically  ill,  whether 
or  not  remuneration  is  in  sight.  But  when  sickness 
has  not  progressed  so  far  that  the  appeal  to  the  physi- 
cian seems  to  the  patient  or  his  friends  a  necessity,  or 
when  an  illness  does  not  apparently  threaten  life, 
but  only  diminishes  comfort  and  working  efficiency, 
the  situation  is  entirely  different.  In  such  cases  a  self- 
respecting  but  poor  family  does  not  readily  seek  medi- 
cal aid  from  a  private  physician,  because  they  face  the 
embarrassment  of  going  to  a  medical  man  whom  they 
do  not  know  and  asking  him  for  a  personal  favor.  For 
such  cases  a  properly  conducted  Dispensary  can  per- 
form a  great  service,  preventing  suffering,  keeping 
wage-earners  at  work,  and  often  obviating  an  onset 
of  grave  disease  due  to  diminished  resistive  power. 

A  woman  entered  a  Dispensary  complaining  of 
certain  troublesome  pelvic  symptoms  which,  though 
not  by  any  means  serious,  had  been  increasing  suf- 
ficiently to  disturb  her  usual  routine.  She  might  have 
dosed  herseK  with  patent  medicines  and  waited  some 
months  before  she  was  really  ''sick.''  It  was  fortu- 
nate she  did  not  wait,  for  gynecological  examination 
indicated,  what  operation  proved  to  be,  cancer.  On 
referring  the  patient  to  the  hospital,  a  bit  of  malignant 
tissue,  no  bigger  than  one's  little  finger,  was  excised. 


286  DISPENSARIES 

A  hospital  without  a  Dispensary  would  have  received 
that  woman,  if  at  all,  when  it  was  too  late  to  save  her 
life,  at  least  without  a  dangerous  and  certainly  mutilat- 
ing operation. 

To  perceive  the  need  for  an  out-patient  department, 
the  superintendent  and  the  trustees  need  to  look  be- 
yond the  four  walls  of  the  institution.  They  may  well 
remember  that  the  community  supports  the  hospital, 
and  that  their  primary  duty  is  to  see  how  the  hospital 
can  serve  the  community  in  any  medical  way.  It  is 
no  credit  to  the  insight  or  initiative  of  hospitals  that 
in  many  communities  outside  agencies  have  had  to 
establish  independent  Dispensaries,  or  to  wait  and 
urge  for  years  that  the  hospital  establish  one.  A  whole 
chain  of  southern  cities,  beginning  with  Memphis, 
started  Dispensaries  through  their  charity  organization 
societies,  instead  of  their  hospitals.  The  latter  in- 
stitutions have  in  some  instances  waked  up  and  taken 
over  the  Dispensary  as  they  should.  In  many  towns 
District  Nursing  Associations  have  fulfilled  the  same 
pioneer  function. 

This  criticism  is,  however,  fully  balanced,  or  over- 
balanced, by  the  striking  growth  of  out-patient  de- 
partments among  the  hospitals  of  the  United  States, 
as  shown  by  the  statistics  in  Chapter  IV. 

Some  local  physicians  would  smile  audibly  at  the 
notion  that  the  hospital  in  their  city  needed  an  out- 
patient department  for  the  benefit  of  the  medical 
profession.  If  physicians  in  a  town  fear  the  competi- 
tion of  an  out-patient  department  with  their  private 
practice,  it  means  either  that  they  do  not  understand 


SMALL   OUT-PATIENT   DEPARTMENT      287 

how  a  good  Dispensary  can  be  run,  or  that  they  do  not 
believe  that  their  hospital  is  capable  of  running  such  a 
Dispensary. 

A  well-equipped  Dispensary  will  aid  the  local  pro- 
fession and  the  public,  by  providing  certain  diagnostic 
facilities  which  would  otherwise  be  accessible  to  but 
few.  Consultation  with  experts  in  laryngology,  op- 
thalmology,  surgery,  etc.,  offers  an  opportunity  to 
patients  for  better  diagnosis  and  to  local  physicians 
for  self -improvement.  The  laboratory  of  the  local 
out-patient  department,  if  equipped  as  it  should  be, 
ought  to  be  available  to  patients  who  are  sent  by  their 
practitioners,  for  analyses  of  urine,  stomach  contents, 
blood-counts  or  other  chemical  or  bacteriological  tests 
which  require  an  expert  clinical  pathologist.  So  with 
tissue  specimens,  as  in  cases  of  possible  cancer. 
Suitable  fees  should  be  charged  for  such  service,  and 
the  patients  should  be  admitted  merely  for  the  test 
desired,  not  to  the  clinic. 

The  function  of  the  X-ray  Department,  along  the 
same  line,  is  equally  important.  The  equipment 
for  Roentgenological  work  is  too  expensive  for  almost 
any  individual  practitioner  in  a  small  community. 
The  cost  of  taking  plates  is  high  enough  at  best,  and 
is  practically  prohibitive  for  the  mass  of  the  people 
unless  the  work  is  done  in  an  institution  which  can 
reduce  the  fixed  charges  to  a  minimum  and  even  do 
some  work  for  less  than  cost.  The  X-ray  service  of 
the  out-patient  department  of  a  small  hospital  should 
be  available  at  cost  for  people  of  moderate  means. 
These  patients  should  be  sent  by  their  physicians, 


288  DISPENSARIES 

whether  or  not  the  latter  are  members  of  the  Dispensary- 
staff.  The  patients  should  be  admitted  for  X-ray- 
only,  not  to  the  Glinic.  Of  course  such  an  X-ray- 
Department  will  do  work  for  private  patients  in  the 
hospital  at  fees  which  are  considerably  above  cost; 
and  for  ward  cases  or  for  general  Dispensary  patients 
for  fees  which  are  not  more  than  cost  and  which  are 
remitted  in  whole  or  in  part  when  the  patient  cannot 
pay.  The  combination  of  the  private,  semi-private 
and  ^^ charitable"  work  may  make  an  X-ray  Depart- 
ment pay  its  expenses  and  at  the  same  time  perform 
a  broad  and  valuable  service. 

The  particular  clinics  which  are  most  needed  by  the 
community,  or  those  which  it  is  most  expedient  to 
undertake  first,  are  matters  for  local  study.  The 
service  of  oculists  or  laryngologists,  for  instance,  may 
be  almost  inaccessible  to  the  mass  of  the  town's 
population.  The  few  men  specializing  along  these 
lines  have  most  of  their  time  filled  by  private  work, 
with  patients  of  the  well-to-do  classes.  A  Throat 
and  Ear  Clinic,  or  an  Eye  Clinic,  may  be  a  boon  to  the 
community.  The  work  of  the  school  doctors  and 
nurses  for  the  children  in  the  public  schools,  also, 
would  be  probably  much  assisted  by  them.  Local 
reasons  for  pediatric,  orthopedic,  surgical  and  general 
medical  clinics,  will  appear  in  addition  to  general  rea- 
sons for  an  out-patient  department  as  a  whole. 


SMALL  OUT-PATIENT   DEPARTMENT      ^80 

Organization  and  Management  of  the  Small  Out-Patient 

Department 

1.  Rooms  and  Equipment.  In  the  chapter  on  build- 
ings, a  suggestion  for  a  plan  of  an  out-patient  depart- 
ment of  a  small  hospital  will  be  found.  It  is  desirable 
that  all  clinics  be  open  at  the  same  time,  as  in  this 
manner  the  patient  secures  the  maximum  benefit  of 
consultation  and  co-operative  diagnosis.  In  starting 
an  out-patient  department  in  quarters  which  had  been 
planned  for  some  other  purpose,  and  which  include  all 
the  space  the  existing  hospital  buildings  can  spare,  it 
is  not  always  possible  to  carry  on  all  cHnics  during  the 
same  hours.  This  difficulty  can  be  partly  avoided  by 
noting  the  second  requirement  carefully. 

Most  of  what  has  been  said  (Chapter  X)  about  the 
equipment  of  particular  clinics  in  the  large  Dispensary 
applies  here,  with  obvious  alterations  in  detail.  Cer- 
tain points  will  be  reiterated  because  of  their  special 
importance. 

Should  a  Dispensary  receive  an  average  number  of 
visits  of,  say,  40  or  50  a  day,  the  range  in  number 
would  probably  be  between  15  and  80  and  sufficient 
space  for  the  maximum  number  must  be  provided  in 
admitting  halls  and  in  waiting-rooms.  Separation  of 
the  sexes  in  the  waiting-rooms  is  essential,  unless  the 
rooms  are  so  placed  as  to  be  constantly  under  the  eye  of 
some  responsible  person  or  are  part  of  a  public  hall 
where  persons  are  frequently  passing.  The  main  ad- 
mission door  should  be  as  accessible  as  possible  from 
the  street,  and  it  is  convenient  to  have  a  vestibule  so 


290  DISPENSARIES 

that  baby  carriages  can  be  left  sheltered  from  the 
weather,  yet  not  in  the  admission  hall  itself. 

In  too  many  clinics  the  surgical  side  gets  the  lion^s 
share  and  the  medical  is  neglected.  The  importance 
of  providing  the  medical  clinic  with  a  microscope, 
blood-pressure  apparatus  and  facilities  for  making  the 
ordinary  urine  tests,  can  hardly  be  over-estimated. 
The  general  laboratory  of  the  hospital  should  be  ac- 
cessible to  the  Out-Patient  Department,  but  since  it  is 
desirable  that  all  medical  patients  should  have  certain 
routine  laboratory  examinations  made,  it  may  be  more 
convenient  to  make  the  routine  tests  for  albumin  and 
sugar  in  the  clinic  itself,  or  close  by. 

The  use  of  the  X-ray  for  diagnosis  is  no  longer 
confined  to  surgical  clinics,  and  the  X-ray  facilities  of 
the  hospital  should  be  made  accessible  to  all  clinics  of 
the  Out-Patient  Department,  as  fully  as  possible. 

2.  Medical  Staff  and  Services.  Have  as  few  clinical 
departments  as  possible,  and  have  as  long  services  in  each 
department  as  possible.  As  pointed  out  in  the  chapter 
on  organization,  a  small  Dispensary,  treating  perhaps 
50  patients  a  day  and  having  ten  different  departments, 
loads  itself  down  with  a  burden  of  administration 
and  enhances  the  difficulty  of  securing  real  medi- 
cal team  work.  The  medical,  surgical  and  children's 
departments  are  fundamental.  The  following  ad- 
ditional clinics  should  usually  be  provided  for:  (1) 
Eye;  (2)  Ear,  Nose  and  Throat  (one  clinic);  (3) 
Dental. 

Orthopedics  is  of  great  and  growing  importance  not 
only  as  a  branch  of  surgery,  but  also  as  an  agent  in 


SMALL   OUT-PATIENT   DEPARTMENT      291 

presentive  and  reconstructive  medicine.  This  is  par- 
ticularly the  case  in  connection  with  postural  and 
structural  defects  among  children,  and  with  the 
rehabilitation  of  wage-earners  after  certain  accidents. 
Few  cities  of  moderate  size  have  had  physicians  with 
special  training  in  orthopedics,  and  clinics  as  well  as 
the  community  at  large  have  had  to  do  without  this 
service.  The  War  is  causing  a  large  number  of  physi- 
cians to  receive  orthopedic  training  and  is  also  calling 
its  value  to  public  attention  as  never  before.  We  may 
hope  that  after  the  close  of  the  War  orthopedics  can 
be  much  more  fully  represented  in  Dispensaries  in  the 
smaller  communities  than  has  thus  far  been  practicable. 
In  some  of  these  Dispensaries  it  will  be  wiser  to  have 
the  orthopedist  work  as  a  member  of  the  general 
surgical  clinic  than  as  head  of  an  independent  depart- 
ment. Decision  on  this  point  must  be  based  in  each 
case  upon  a  careful  weighing  of  all  factors  in  the  im- 
mediate local  situation. 

The  provision  of  special  clinics  for  tuberculosis, 
syphilis  and  gonorrhea,  should  be  considered  as  part 
of  the  public  health  provisions  in  the  community ;  and 
the  hospital  should  co-operate  in  the  development  of 
these  with  the  public  health  authorities,  or  with  a 
voluntary  body  such  as  a  tuberculosis  society.  An 
outgrowth  of  the  children's  clinic  may  be  a  well  ba- 
bies' clinic  co-operating  with  a  local  baby  welfare  as- 
sociation or  with  the  Department  of  Health. 

The  out-patient  services  should  be  intimately  cor- 
related with  those  in  the  hospital.  The  best  plan  is 
that  one  of  the  chief  assistants  in  the  hospital  service 


292  DISPENSARIES 

should  be  the  chief  of  the  out-patient  service  in  the 
corresponding  clinic,  medical  or  surgical.  There  are 
out-patient  departments  in  which  this  system  pre- 
vails nominally,  but  in  which  the  so-called  '^  chief* 
gives  no  real  attention  to  the  out-patient  department. 
This  is  valueless. 

3.  Admissions  and  Fees.  The  general  principles 
brought  out  in  previous  chapters  apply  fully.  Always 
it  is  necessary  that  the  responsibility  for  admitting 
patients  be  concentrated  in  the  hands  of  one  person. 
Usually  it  is  best  that,  in  the  small  out-patient  depart- 
ment, this  person  be  a  member  of  the  Social  Service 
Department;  the  member  if  the  ^'Department"  has 
only  one  worker.  A  paid  clerk  is  an  administrative 
necessity  unless  the  Dispensary  is  very  small  indeed. 
The  clerk  should  be  on  duty  during  clinic  hours  to 
help  with  the  admissions,  fees  and  records,  and  may 
do  record  work  at  other  hours  if  required,  or  assist 
elsewhere  in  the  hospital. 

The  desirability  and  practicabiUty  of  a  Fee  System 
need  not  be  re-argued.  The  admitting  officer  should 
be  responsible  for  remitting  fees. 

4.  Records,  The  form  of  clinic  records  may  follow 
those  used  in  large  Dispensaries.  The  alphabetical 
index  to  all  patients  is  of  vital  importance.  The 
clinic  records  are  best  filed  by  number  and  kept  near 
the  admission  desk.  Thence  they  may  be  distributed 
to  the  clinics  as  the  patients  go  in.  The  follow-up 
system  described  for  large  Dispensaries  can  be  fol- 
lowed closely  in  small  ones,  except  that  where  the 
total  daily  attendance  averages  under  100,  a  single 


SMALL  OUT-PATIENT  DEPARTMENT      293 

follow-up  index  at  the  admission  desk  might  serve  all 
clinics,  instead  of  having  separate  indexes  in  each 
clinic.  The  statistical  record  forms  described  for  large 
Dispensaries  require  little  or  no  modification  in  the 
small  institution  except  that  there  will  be  fewer 
clinics. 

5,  Nursing  and  Social  Service.  The  hospital  should 
assign  a  graduate  nurse  to  the  out-patient  department 
if  there  is  any  surgical  work  to  be  done.  A  pupil 
nurse  may  be  assigned  to  the  medical,  the  children's 
department,  etc.,  to  assist  in  preparing  patients  for 
examination,  weighing  babies,  etc.  Out-patient  work 
is  valuable  experience  for  nurses  in  training.  Certain 
conditions  are  seen  which  do  not  appear  in  the  hospital 
wards.  The  nurse  learns  how  to  deal  with  patients 
who  are  not  flat  on  their  backs.  The  pupil's  executive 
ability,  if  she  has  any,  will  be  brought  out  in  the 
clinic. 

The  need  for  organized  Social  Service  in  the  small 
Out-Pat ient  Department  is  as  great  as  in  the  larger. 
The  opportunity  for  service  in  the  community  of 
moderate  size  is  often  greater,  or  at  least  the  results 
will  be  more  apparent. 

A  few  practical  hints  may  be  given  concerning  the 
salaried  staff  in  a  small  Out-Patient  Department.  If 
a  small  Out-Patient  Department  can  employ  only  one 
full-time  salaried  person,  this  person  should  be  a 
trained  social  worker  who  has  also  had  a  nurse's 
training.  She  should  have  charge  of  the  admissions 
as  registrar,  and  supervision  of  the  executive  details 
of  the  Dispensary. 


294  DISPENSARIES 

If  a  Dispensary  is  large  enough  to  require,  and  wise 
enough  to  afford,  two  or  more  salaried  persons,  the 
person  possessing  the  joint  training  of  a  social  worker 
and  a  nurse  (the  training  of  a  social  worker  does  not 
mean  a  month  or  two  of  observation  in  some  well- 
established  social  service  department,  but  a  really 
extended  and  adequate  course  of  training)  should,  as 
before,  be  responsible  for  the  general  supervision  of 
the  executive  work  of  the  Dispensary  and  should  take 
charge  of  the  admitting.  She  should  be  responsible 
to  the  superintendent  of  the  hospital.  The  second 
person  employed  should  be  a  graduate  nurse  who  does 
nursing  work  only,  and  who  is  responsible  to  the  execu- 
tive. If  one  or  more  pupil  nurses  are  then  detailed  to 
the  Dispensary,  they  come  under  this  graduate  nurse, 
subject  to  the  educational  oversight  of  the  superin- 
tendent of  nurses.  The  graduate  nurse  should  take 
charge  of  the  medical  and  surgical  supplies  used  in  the 
Dispensary,  be  responsible^for  the  care  of  instruments, 
etc.  Should  there  be  need,  an  assistant  social  worker 
doing  only  social  work  should  be  provided,  who  will 
have  no  executive  responsibility,  but  merely  do  case 
work.  A  clerk  to  assist  the  executive  head  of  the 
Dispensary,  keeping  statistics,  filing,  and  doing  clerical 
work  on  the  medical  and  social-service  records,  may 
be  needed  even  before  any  other  salaried  assistant  will 
be. 

6.  Cost  and  Finance.  Even  a  small  Out-Patient 
Department  cannot  be  run  for  nothing,  and  a  good 
Out-Patient  Department  cannot  be  run  for  next  to 
nothing !     The  best  unit  of  expense  is  the  average  cost 


SMALL  OUT-PATIENT   DEPARTMENT      295 

per  visit,  obtained  by  dividing  the  total  expense  of 
the  Out-Patient  Department  by  the  whole  number  of 
visits  paid  by  all  patients.  If  the  hospital  keeps  pro- 
per accounts  and  charges  to  the  Out-Patient  Depart- 
ment its  fair  share  of  the  general  hospital  expenses,  as 
well  as  the  special  expenses  for  the  Dispensary,  the 
cost  per  visit  should  not  be  expected  to  be  less  than  40 
cents.  The  fees  charged  patients  may  be  expected  to 
bring  back  thirty  to  fifty  per  cent  of  the  expense,  at  a 
Dispensary  doing  primarily  charitable  work,  with  an 
unsalaried  medical  staff. 

In  raising  funds,  success  depends  on  doing  good  work 
and  telling  the  public  about  it  intelligently  and  per- 
sistently. This  is  particularly  true  in  the  small 
community.  Dispensary  work  makes  a  strong  appeal, 
because  it  is  concrete,  because  it  deals  with  large 
numbers,  because  it  relieves  suffering  in  very  obvious 
ways,  and  because  it  is  preventive  and  can  be  put 
before  men  who  give  not  only  because  their  hearts  are 
touched,  but  because  their  heads  approve.  A  well- 
managed  out-patient  service  ought  to  develop  new 
lines  of  public  interest  and  support  for  the  hospital  as  a 
whole. 

7.  General  organization  of  the  Small  Out-Patient 
Department.  Do  not  expect  to  maintain  a  Dispensary 
successfully,  to  have  it  do  work  that  is  worth  serious 
medical  consideration,  or  stand  intelligent  public 
criticism,  if  the  Out-Patient  Department  is  allowed  to 
run  itself  with  the  medical  head  of  each  clinic  changing 
every  few  months  and  running  his  own  little  kingdom 
by  himself.     The  principle  of  organization  should  b^ 

20 


296  DISPENSARIES 

to  centralize  the  executive  control  as  fully  as  possible, 
even  in  a  small  Dispensary,  by  employing  such  an 
executive  as  has  been  suggested,  and  to  leave  to  the 
physician  full  responsibility  for  his  proper  work,  the 
diagnosis  and  treatment  of  patients.  There  should  be 
a  special  Dispensary  Committee  of  the  Trustees,  and 
a  Dispensary  Committee  of  the  Medical  Staff.  The 
executive  of  the  Dispensary  should  be  directly  re- 
sponsible to  the  superintendent  of  the  hospital. 
Efficient  dealing  with  numbers  of  people  requires 
organization.  The  first  demand  of  efficient  organiza- 
tion is  a  head. 


PUBLIC  HEALTH   DISPENSARY  297 


CHAPTER   XVIII 

PUBLIC     HEALTH    DISPENSARIES    AND     HEALTH 

CENTERS 

We  have  seen  that  for  the  past  fifteen  years  the  pub- 
lic health  motive  has  been  one  of  the  active  forces 
creating  Dispensaries.  From  1905  to  1916,  more  than 
a  thousand  Dispensaries  were  established  as  a  result  of 
it.  It  remains  to  consider  the  different  types,  and 
the  administrative  methods,  of  Dispensaries  of  this 
class. 

The  Tuberculosis  Dispensary 

The  growth  of  tuberculosis  Dispensaries,  from  about 
20  in  1905  to  500  in  1916,  has  taken  place  in  response 
to  the  demand  for  dealing  with  a  serious  and  prevalent 
disease,  despite  the  fact  that  private  medical  practice, 
already  in  the  field,  was  supposed  to  be  coping  with 
it.  The  medical  profession,  as  well  as  the  general 
public,  has  favored  the  tuberculosis  Dispensary,  It 
has  been  recognized  that  the  expense  of  diagnosing 
and  treating  tuberculosis  is  too  heavy  for  many  to 
bear.  It  has  also  been  perceived  that  in  dealing  with 
such  a  disease,  private  medical  practice  falls  short 
because  it  cannot  be  militant.  The  tuberculosis 
Dispensary  set  a  standard  for  all  public  health  Dis- 
pensaries and  all  future  public  health  campaigns,  by 
dropping  the  passive  or  receptive  attitude  of  the 


298  DISPENSARIES 

traditional  Dispensary  and  doing  instead  what  the 
advertising  men  call  ^'going  out  after  the  business.'^ 
It  did  and  does  this  partly  through  distributing 
literature,  putting  up  posters,  holding  lectures  and 
exhibits;  but  still  more  effectively  by  employing  a 
field  agent, — the  uncommercial  traveler  of  public 
health  work — the  visiting  nurse. 

In  Pennsylvania,  a  few  years  ago,  a  tuberculosis 
Dispensary  was  established  by  law  in  every  county  of 
the  state.  In  many  of  the  smaller  places,  starting  the 
'' Dispensary"  consisted  merely  in  engaging  a  physi- 
cian to  hold  certain  advertised  office  hours  for  tubercu- 
losis cases,  no  charge  being  made  to  such  patients. 
The  equipment  was  merely  that  of  the  physician's 
private  office,  with  the  very  important  addition  that  a 
visiting  nurse  of  the  state  service  was  provided  as  his 
assistant.  The  provision  of  this  nurse  was  in  fact  the 
essential  creative  element  in  the  Dispensary,  rendering 
it  an  active  educational  force. 

The  arrangement  and  equipment  of  a  tuberculosis 
Dispensary  may  be  extremely  simple.  An  admitting 
room  and  an  examining  room,  where  there  is  reason- 
ably good  light,  and  comparative  quiet,  are  essential. 
A  large  tuberculosis  Dispensary  would  have  a  large 
admitting  room  where  twenty-five  or  more  patients 
could  wait  at  one  time,  and  several  examining  rooms. 
Even  in  a  small  clinic  it  is  desirable  to  have  two  ex- 
amining rooms.  These  need  not  be  more  than  six  by 
eight  feet,  although  a  slightly  larger  size  is  more  con- 
venient. Even  with  only  one  physician,  it  saves  time 
to  have  two  rooms.     A  patient  can  be  prepared  for 


PUBLIC   HEALTH   DISPENSARY  299 

examination  in  one  room,  while  the  physician  is  en- 
gaged in  the  other.  The  visiting  nurse  should  be  in 
attendance  at  the  clinic,  to  take  a  history  from  new 
patients,  start  the  record  card,  and  pass  it  on  to  the 
physician.  Details  of  organization  and  management 
of  tuberculosis  Dispensaries  have  been  treated  in 
many  of  the  publications  of  the  National  Association 
for  the  Study  and  Prevention  of  Tuberculosis,  of 
local  anti-tuberculosis  societies,  and  in  the  useful 
handbook  of  Miss  F.  Elizabeth  Crowell. 

The  differential  diagnosis  of  tuberculosis  in  ques- 
tionable cases  often  requires  skill  and  facilities  not  at 
the  command  of  the  small  clinics  thus  described. 
There  have  been  established  a  few  large  tuberculosis 
Dispensaries  equipped  for  research,  such  as  the  Henry 
Phipps  Institute  in  Philadelphia,  but  the  number  of 
these  will  remain  small.  Most  will  be,  and  should  be, 
attached  to  general  hospitals.  In  a  large  city,  all 
local  tuberculosis  Dispensaries  should  be  affiliated, 
and  there  should  be  such  relations  with  the  general 
hospitals  and  out-patient  departments  as  shall  enable 
any  form  of  special  examination  to  be  readily  secured. 
That  the  whole  system  of  local  tuberculosis  clinics  and 
hospitals  should  be  under  one  management,  that  of 
the  Department  of  Health,  is  indubitably  best. 

The  operation  of  a  tuberculosis  Dispensary  is  a 
branch  of  public  health  work.  The  visiting  nurse  is 
to  follow  up  cases  into  their  homes.  She  is  to  in- 
vestigate the  families,  she  is  to  bring  in  all  the  members 
of  the  family  of  a  tuberculosis  patient  for  examination. 
The  nurse  arranges  the  details  in  getting  a  patient  into 


300  DISPENSARIES 

a  sanitorium;  she  serves  as  a  link  between  the  sanito- 
rium  and  the  home  when  the  patient  is  discharged. 
It  is  good  general  policy  that  sanitoriums,  when  lo- 
cated at  a  distance  from  congested  districts,  should 
not  send  their  own  workers  to  do  detailed  follow-up 
work,  but  should  utilize  their  social  workers  merely 
to  make  connecting  links  between  the  discharged  pa- 
tient and  the  tuberculosis  Dispensary  nearest  to  the 
patient's  home. 

**Baby  Clinics" 

Out-Patient  clinics  for  babies  and  young  children 
have  been  quite  generally  established  as  departments 
of  general  Dispensaries,  and  in  connection  with  special 
hospitals  for  babies  and  children.  The  public  health 
clinic  for  babies  is  not  primarily  for  the  treatment  of 
the  sick,  but  is  to  keep  babies  well.  Sometimes  these 
clinics  are  called  ''Well  Baby  Clinics";  sometimes 
''Infant  Welfare  Stations '';  and  sometimes  "Baby 
Welfare  Consultation  Stations.''  The  term  "Milk 
Station"  is  being  rapidly  superseded  by  other  terms. 
In  all,  the  essential  equipment  consists  of  a  few  rooms 
for  seeing  the  babies  and  their  mothers,  scales,  and  a 
few  other  inexpensive  articles.  The  Staff  required  is 
the  same  as  at  the  tuberculosis  Dispensary, — the  doctor 
and  the  visiting  nurse. 

Historically,  "baby  clinics"  usually  began  as  efforts 
to  prevent  infant  mortality  by  providing  pure  milk. 
They  were  milk  stations,  at  which  milk  of  good  quality 
was  sold  at  cost,  or  given  away  free  when  the  price 
could  not  be  paid.     Inasmuch  as  the  best  milk  for 


PUBLIC   HEALTH   DISPENSARY  301 

a  little  baby  is  the  mother^s  milk,  it  was  soon  seen  that 
distributing  cows'  milk  was,  in  a  measure,  a  discourage- 
ment to  breast  feeding,  or  at  least  that  it  was  an  in- 
adequate and  partial  method  of  meeting  the  larger 
need  of  the  situation.  The  baby  clinic,  as  such,  de- 
veloped to  supply  the  really  essential  needs,  namely, 
medical  supervision  of  the  health  of  the  baby  and  the 
practical  education  of  the  mother  in  its  feeding  and 
care.  The  doctor  must  diagnose  the  case  and  outline 
the  plan  for  teaching  the  mother.  The  nurse  is  the 
doctor's  right  hand  in  making  the  program  for  care 
effective,  by  her  contact  with  the  mother  in  the  clinic 
and  in  the  home. 

The  baby  clinic  has  a  local  clientele.  Only  a  very 
small  proportion  of  mothers  can  or  will  bring  their 
babies  more  than  a  few  blocks  away  from  where  they 
live.  Experience  has  demonstrated  that  while  a 
mother  anxious  about  a  sick  baby  will  go  a  longdistance 
to  a  clinic  or  hospital,  preventive  work  such  as  in  the 
well  baby  clinic  must  be  brought  close  to  the  home. 

As  to  equipment,  a  small  baby  clinic  can  manage 
with  a  single  room  large  enough,  say,  for  several 
mothers  to  wait  as  the  doctor  examines  their  babies 
one  by  one.  But  for  convenient  and  efficient  working, 
the  baby  clinic  should  include  the  following:  First, 
an  admission  room,  where  the  mothers  may  sit  com- 
fortably; second,  a  clinic  room  where  the  doctor  has 
his  place  for  seeing  the  babies  individually,  and  where 
they  can  be  weighed  and  examined;  third,  a  milk 
laboratory  or  demonstration  room  where  the  processes 
of  modifying  milk  can  be  explained.     The  admission 


302  DISPENSARIES 

room,  or  preferably  the  demonstration  room,  should 
be  large  enough  and  be  so  arranged  that  a  group  of 
mothers  may  be  gathered  together  for  a  talk  by  the 
doctor.  The  walls  and  tables  along  one  side  of  the 
same  room  should  be  available  for  pictures  and  ex- 
hibits of  baby  clothes,  etc. 

It  is  evident  from  this  description  that  the  rooms 
used  by  a  medical  clinic  in  a  general  Dispensary  can 
be  readily  adapted  to  the  purpose  of  a  baby  welfare 
clinic,  but  of  course  the  mothers  and  babies  must  have 
the  exclusive  use  of  them  during  the  hours  the  baby 
clinic  is  in  operation.  Publications  of  the  New  York 
Milk  Committee  have  shown  how  a  floor  of  a  typical 
tenement  or  house  can  be  arranged  for  the  use  of  a 
baby  clinic. 

The  doctor's  part  in  the  baby  clinic  is  generally 
confined  to  periodical  examination  of  the  baby  and 
advice  to  the  mother.  This  is  usually  once  a  week, 
but  may  be  less  frequent  when  the  baby  is  older  or  is 
getting  on  without  trouble.  In  the  pediatric  depart- 
ments of  general  Dispensaries,  the  same  type  of  work 
is  often  carried  on  as  part  of  the  clinic,  or  as  a  separate 
branch  of  the  clinic;  sick  babies  being  also  treated. 
In  the  local  Baby  Clinic,  however,  the  physician  is 
usually  not  allowed  to  give  treatment  to  sick  babies. 
The  Baby  Clinics  have  thus  endeavored  to  avoid 
competition  with  the  medical  profession  of  the  locality, 
and  have  invited  them  to  send  difficult  feeding  cases, 
with  the  understanding  that  no  sick  cases  would  be 
treated.  Separation  between  the  function  of  the 
doctor  in  the  clinic  and  the  doctor  in  the  home  may  be 


PUBLIC   HEALTH   DISPENSARY  303 

necessary  under  some  circumstances  and  for  a  tem- 
porary period,  but  is  not  a  permanently  satisfactory 
relation  on  either  side. 

The  Milk  Station  is  very  frequently  combined  with 
the  Baby  Welfare  Clinic,  the  milk  being  usually  sold 
at  cost.  The  milk  is  delivered  daily  at  the  clinic, 
suitably  iced,  and  can  be  had  by  the  families  at  speci- 
fied hours.  Sometimes  the  milk  is  furnished  modified 
according  to  the  formula  prescribed  by  the  doctor. 
A  central  laboratory  may  put  up  the  formulae  in 
bottles  ready  for  delivery  at  the  station,  but  the  far 
better  plan  is  to  provide  whole  milk  and  to  have  the 
nurse  teach  the  mother  in  her  home  how  to  modify 
this  milk  herself.  At  first  thought,  it  might  seem  that 
often  this  could  not  be  done,  but  the  experience  of 
many  cities  has  conclusively  demonstrated  that  the 
plan  of  home  modification  is  not  only  practical,  but 
in  a  large  majority  of  cases  is  in  every  way  beneficial. 

The  whole  trend  of  Baby  Clinics,  however,  has  been 
away  from  the  mere  provision  of  milk  and  toward 
emphasis  on  breast  feeding.  Every  effort  is  made  to 
persuade  mothers  to  nurse  their  babies  and  to  get  and 
keep  the  mothers  in  such  physical  condition  that  they 
can  nurse  them.  Herein,  as  we  shall  see,  the  public 
health  Dispensary  for  babies  comes  close  to  that  for 
obstetrical  and  prenatal  care. 

Prenatal  or  Pregnancy  Clinics 

Historically,  the  development  of  the  infant  welfare 
campaign  in  this  country  began  with  the  baby,  often 
merely  with  providing  pure  milk  for  babies.     It  has 


304  DISPENSARIES 

come  to  emphasize  education  more  than  milk;  and  is 
advancing  to  include  obstetrical  and  prenatal  care. 
The  emphasis  of  the  infant  welfare  campaign  has 
shifted,  and  must  further  shift,  from  milk  to  mother- 
hood. The  Federal  Children's  Bureau  has  devoted 
much  attention  to  the  subject  of  prenatal  and  ob- 
stetrical care,  in  the  endeavor  to  waken  the  public 
to  a  sense  of  the  magnitude  of  unnecessary  suffering 
and  death  among  mothers  and  babies,  and  the  pos- 
sibility of  largely  alleviating  this.  The  purpose  and 
method  to  be  followed  are  in  brief : — ^^ 

(1)  The  Preg-  (1)  By  making  proper  medical  examination,  pelvic 
nancy  measm-ements,  etc.,  of  pregnant  women  before  con- 
Clinic  finement   (when  possible,  some  months  before),   to 

decide  whether  normal  delivery  is  possible  or  likely, 
and  to  give  such  medical  advice  as  may  be  indicated 
for  the  comfort  and  safety  of  all  women,  and  in  partic- 
ular when  hospital  care  and  operation  are  necessary. 

(2)  Prenatal  (2)  By  visits  from  a  trained  visiting  nurse  and 
Nursing          reports  to  the  physician,  during  the  course  of  preg- 
nancy, to  instruct  the  mother  and  father  in  the  hygiene 
of  pregnancy,  and  to  make  the  best  possible  prepara- 
tion of  the  home  for  the  sake  of  the  coming  child. 

(3)  Obstetrical  (3)  By  expert  medical  care  at  confinement,  to 
Care  minimize  the  risks  to  mother  and  child. 

(4)  Post-Par-  (4)  By  frequent  visits  from  the  nurse  during  the 
tem  Care        two  weeks  or  so  following  confinement,  to  provide 

needed  bedside  care  to  the  mother  and  give  the  baby 
the  best  start  possible. 

Items  (1)  and  (2)  include  ^'prenatal  care,''  a  purely 
preventive  and  educational  service.  It  may  of  course 
be  provided  either  in  conjunction  with  or  independently 
of  (3)  and  (4) .  The  obstetrical  care  (3)  may  be  given 
by  a  private  physician,  under  whom  the  visiting  nurse 


PUBLIC   HEALTH   DISPENSARY  305 

gives  the  post-partem  care.  Visiting  nursing  associa- 
tions seem,  as  yet,  rarely  able  to  provide  a  nurse  to  be 
present  at  the  confinement,  owing  to  the  expense  and 
the  administrative  difficulty  of  combining  such  a  serv- 
ice with  the  nurses^  other  work.  Efforts  are  being 
made  in  this  direction. 

The  pregnancy  clinic  itself  is  the  initial  and  guiding 
factor  in  this  chain  of  preventive  service.  Its  minimum 
equipment  should  include  a  waiting-room  of  suitable 
size,  a  smaller  ''history  room,"  and  an  examining 
room.  The  last  must  have  a  gynecological  examining 
table  and  a  sterilizer  for  the  examining  instruments. 
While  a  patient  is  being  prepared  by  the  nurse  for  local 
examination,  the  doctor  may  be  in  another  room  (the 
''history  room")  taking  the  history  of  a  new  case,  or 
giving  his  advice  to  a  patient  whom  he  has  already 
examined. 

The  doctor's  examination  may  reveal  that  the  ex- 
pectant mother  is  not  likely  to  have  a  normal  delivery, 
and  he  may  therefore  advise  a  hospital.  The  nurse 
helps  the  patient  and  her  family  to  arrange  for  this. 
In  any  event  the  nurse  visits  the  home  regularly,  as  a 
rule  about  every  ten  days,  to  watch  the  mother's 
condition,  teach  her  what  she  needs  to  know  about  the 
care  of  herself  and  of  the  coming  child,  and,  when 
necessary,  to  aid  (or  secure  aid)  in  such  prenatal  de- 
tails as  baby-clothes,  linen,  etc.  Once  a  month,  or  as 
directed  by  the  physician,  a  specimen  of  urine  is  ex- 
amined. It  is  of  course  desirable  that  the  prenatal 
service  shall  begin  early  in  pregnancy.  Subsequent 
visits  of  the  expectant  mother  to  the  clinic  may  be 


306  DISPENSARIES 

made  if  advised  by  the  nurse,  and  are  usually  desired 
by  the  physician  at  least  once  during  the  last  few  weeks 
of  pregnancy.  The  pregnancy  clinic  and  prenatal 
work  are  most  efficient  when  connected  with  a  hospital 
to  which  ill  or  operative  cases  may  be  sent  promptly 
and  without  break  in  medical  supervision.  The 
prenatal  and  obstetrical  service  may  obviously  be  made 
part  of  a  medical  educational  system,  as  is  done  with 
great  advantage  in  a  number  of  cities. 

A  pregnancy  clinic  is  influenced  by  location,  but  its 
range  is  not  nearly  so  small  as  that  of  the  baby  clinics. 
Obviously,  a  system  of  prenatal  clinics  in  a  community 
bears  a  close  relation  to  the  well-baby  clinics.  The 
same  rooms  can  be  adapted  to  both  uses  at  different 
hours.  The  visiting  nursing  staff  ought  to  be  the 
same. 

Dr.  J.  Whitridge  Williams,^^  from  an  extensive  study 
of  cases,  estimates  that  the  application  of  proper 
standards  of  prenatal  and  obstetrical  service  would 
reduce  the  infantile  mortality  (up  to  two  weeks  after 
birth)  to  fifty  per  cent  of  that  which  it  would  be  with- 
out such  care.  Actual  field  work  in  Boston  and  New 
York  has  produced  an  average  reduction  of  fully  this 
amount,  and  in  some  years  of  much  more.  The  reduc- 
tion in  infantile  death-rate  extends  throughout  the 
whole  of  the  first  year,  for  the  baby  is  given  a  better 
start  and  breast  feeding  especially  is  promoted.  The 
extension  of  prenatal  care,  and  of  pregnancy  clinics, 
to  reach  a  larger  proportion  of  expectant  mothers 
everywhere, — usually  the  rural  districts  are  most  of  all 


PUBLIC   HEALTH  DISPENSARY  307 

in  need, — is  capable  of  reducing  the  present  staggering 
waste  of  maternal  and  of  infant  life.* 

School  Children's    Clinics 

In  the  systems  of  medical  school  inspection  which 
have  swept  over  the  country  within  recent  years,  the 
first  problem  that  usually  called  the  doctor  into  the 
school  building  was  that  of  contagious  disease.  The 
work  has  rapidly  broadened  to  include  the  detection 
and  the  remedy  of  physical  defects.  To  find  out 
children  with  poor  eyesight,  bad  teeth,  enlarged  ton- 
sils, diseased  hearts,  or  faulty  posture,  requires  physi- 
cal examination.  In  the  best  systems  of  medical 
school  inspection,  this  is  a  periodical  examination. 

But  the  detection  of  physical  defects  takes  us  only  a 
httle  way.  The  defects  detected  cry  for  remedy. 
In  some  cases,  the  parents  are  sufficiently  awake  to  the 
situation  when  it  is  called  to  their  attention,  and  are 
sufficiently  well  provided  with  this  world's  goods  to 
have  a  private  physician  or  surgeon.  But  in  a  large 
proportion  of  cases  the  money  is  lacking.  The  special- 
ized services  which  are  generally  required  are  all 
relatively  expensive.  Here  is  a  peculiarly  suitable 
field  for  the  clinic.  In  communities  where  Dispen- 
saries are  in  existence,  school  children  are  sent  thither 
for  care.  Such  children  constitute  as  much  as  twenty 
per  cent  of  the  entire  clientele  of  some  large  Dispen- 
saries. Where  there  are  no  general  Dispensaries,  or 
where  the  number  has  been  inadequate  and  the  loca- 

*The  Children's  Bureau  estimates  that  in  1913  there  were  at  least 
15,000  deaths  of  women  from  conditions  directly  caused  by  childbirth, 
nearly  all  preventable.    Publication^No.  19  (1917). 


308  DISPENSARIES 

tions  inconvenient,  special  school  children's  clinics 
have  been  established.  Sometimes  these  have  been 
put  into  public  school  buildings  themselves;  sometimes 
they  have  been  added  to  existing  Dispensaries,  and 
opened  at  hours  suited  to  the  children.  In  some 
cities,  however,  the  wise  rule  has  been  adopted  that 
being  away  from  school  for  the  purpose  of  being  treated 
for  a  defect  discovered  by  the  school  physician  or 
teacher  does  not  count  as  a  school  '^  absence. '^ 

The  equipment  of  a  school  children's  clinic  for  eye, 
throat,  or  dental  work,  follows  that  outlined  in 
Chapter  X.  A  large  element  in  efficiency,  here  as  in 
other  public  health  clinics,  is  the  visiting  nurse.  The 
school  nurse  makes  the  difference  between  getting 
things  done  and  merely  recommending  that  they  be 
done.  In  the  oft-quoted  experience  of  New  York 
City,  the  percentage  of  the  school  physicians'  recom- 
mendations which  were  carried  out  was  found  to  be 
six  per  cent  before  the  introduction  of  school  nurses; 
thereafter  it  rose  to  eighty-four  per  cent!  The  dis- 
pensary clinic  is  a  vital  factor,  for  either  in  the  small 
town  or  the  large  city,  dependence  on  private  practice 
for  the  various  special  services  required  never  yields 
more  than  a  small  percentage  of  the  possible  results. 

Psychiatric  Clinics 

A  movement  for  Mental  Hygiene,  now  well  organ- 
ized on  a  national  scale,  has  pursued  a  course  similar 
in  many  respects  to  the  anti-tuberculosis  campaign. 
Educational  work  has  been  developed,  and  a  program 
for  (1)  the  medical  supervision  of  ambulatory  cases  of 


PUBLIC   HEALTH   DISPENSARY  309 

mental  disease,  particularly  in  their  early  stages;  (2) 
for  following  up  patients  discharged  from  psychopathic 
or  insane  hospitals;  and  (3)  for  thorough  examination 
and  diagnosis  of  cases  of  suspected  mental  disease  and 
defect. 

This  program  has  necessarily  led  to  the  establish- 
ment of  psychiatric  clinics.  A  few  large  special 
hospitals  have  been  founded,  such  as  the  Phipps  In- 
stitute in  Baltimore  and  the  Psychopathic  Hospital  in 
Boston,  for  diagnosis,  treatment  and  research.  In 
both  of  these  institutions,  very  great  emphasis  has 
been  laid  upon  the  out-patient  department.  For  the 
purpose  of  diagnosis  of  early  cases  and  for^medical 
supervision  of  psychopathic  cases  in  the  community,  a 
number  of  special  local  clinics  have  been  established. 
In  Massachusetts,  each  of  the  State  Hospitals  for  the 
Insane  has  an  out-patient  clinic,  either  in  the  hospital 
itself  or  the  nearest  city;  these  clinics  providing  both 
for  the  after-care  of  discharged  patients  living  in  the 
neighborhood,  and  for  the  examination  of  persons  who 
come  voluntarily  or  who  are  referred  to  the  specialist. 
For  the  efficient  conduct  of  the  follow-up  and  educa- 
tional work  connected  with  such  clinics,  connection 
with  a  public  health  nursing  service  is  as  essential  as 
in  the  other  types  of  clinics  just  described. 

The  psychiatric  clinic  bears  a  close  relationship  to 
the  problem  of  the  defective  and  the  delinquent.  In 
the  juvenile  court  and  in  the  prison,  there  is  need  for 
the  detection  and  classification  of  mental  diseases, 
and  especially  of  mental  defects.  Examining  clinics 
in  connection  with  courts  and  the  prisons  are  rapidly 


310  DISPENSARIES 

developing  and  are  certain  to  have  a  profound  influence 
over  the  treatment  of  delinquents.  In  the  public 
school  the  special  examination  of  children  to  determine 
their  mental  condition  is  an  outgrowth  of  the  general 
medical  examination.  A  specialist  being  necessary  to 
determine  the  mental  grade  of  the  child,  clinics  have 
been  established  for  this  service.* 

The  Industrial  Clinic 

By  this  is  meant  a  clinic,  or  a  set  of  clinics  constitut- 
ing a  Dispensary,  maintained  in  an  industrial  or  com- 
mercial establishment  for  the  prevention  and  cure  of 
disease  among  the  employees.  Many  business  men 
have  come  to  appreciate  that  health  in  the  worker  is 
one  of  the  most  important  elements  in  industrial 
efficiency.  Workmen's  compensation  laws  have  stim- 
ulated the  ''Safety  First"  movement,  and  the  prompt 
and  efficient  care  of  accidents.  Indirectly  this  has 
helped  to  advance  other  forms  of  health  work  in  in- 
dustry. Such  industrial  health  work  covers  a  wide 
range,  such  as: — 

(1)  First  aid.  This  may  mean  merely  "first  aid  boxes," 
with  or  without  a  nurse  in  attendance. 

(2)  A  surgical  clinic  for  temporary  aid,  dressings,  and  the 
immediate  care  of  minor  accidents  and  emergencies. 

(3)  A  definite  medical  staff:  a  physician  or  surgeon  at- 
tending at  periodic  intervals,  or  a  permanent  staff  of  physi- 
cians examining  and  treating  employees. 

*  On  the  equipment  and  administration  of  psychiatric  cHnics,  see  the 
publications  of  the  National  Committee  on  Mental  Hygiene,  also  of 
various  State  Committees,  and  those  of  the  Sub-Committee  on  Clinics  of 
the  New  York  Committee  on  Feeble-mindedness,  105  East  22d  Street, 
New  York  City. 


PUBLIC   HEALTH   DISPENSARY  311 

(4)  Specialists,  such  as  dentists,  oculists,  etc.,  providing 
service  which  may  be  particularly  needed  among  the  work- 
ers in  a  certain  industry  or  group. 

(5)  Hospital  beds  as  part  of  the  industrial  health  estab- 
lishment. These  are  usually  found  only  in  large  industries, 
or  in  isolated  plants.  Sometimes  beds  in  an  outside  hospital 
are  contracted  for. 

(6)  A  public  health  nurse,  "industrial  visiting  nurse" 
so-called,  who  may  give  part  of  her  time  to  work  in  the 
factory  or  shop  itself,  and  part  to  visiting  in  the  homes  of 
employees,  following  up  accident  cases,  helping  in  bedside 
care,  etc.  Medical  or  surgical  facilities  may  exist  without  a 
nurse,  and  on  the  other  hand,  public  health  nurses  are  pro- 
vided in  some  establishments  without  any  physician  in 
attendance. 

(7)  Educational  work:  distribution  of  health  leaflets; 
posters,  talks,  etc. 

Obviously  certain  phases  of  the  work  just  mentioned 
take  the  industry  much  farther  than  others  into  health 
service.  Large  isolated  plants,  such  as  the  Colorado 
Fuel  and  Iron  Company,  practically  constitute  the  only 
organized  resource  in  the  community.  Its  workers 
and  their  families  are  the  community.  In  another 
large  steel  works,  not  so  isolated,  there  has  been  es- 
tablished a  completely  equipped  dispensary  building 
with  a  few  hospital  beds.  There  is  a  permanent  staff 
of  at  least  four  physicians,  a  large  staff  of  nurses,  some 
serving  in  the  hospital,  others  visiting  in  the  homes, 
and  there  is  an  arrangement  with  an  outside  hospital  for 
caring  for  serious  illness  for  which  the  emergency  beds 
in  the  dispensary  building  are  not  suited.  Every 
employee  is  examined  at  the  time  of  application  for 

21 


312  DISPENSARIES 

employment,  and  treatment  for  accident  or  any  other 
illness  arising  while  the  employee  is  at  work,  is  pro- 
vided. Facilities  for  caring  for  illness  in  their  homes 
are  likely  to  develop  also.  More  than  one  large  com- 
mercial enterprise  maintains  a  clinic  with  a  nurse  al- 
ways in  attendance  and  a  physician  visiting  at  certain 
times.  Those  who  suffer  from  minor  illness  can  have 
prompt  attention,  and  those  who  wish  to  consult  the 
physician  may  do  so  at  the  specified  hours. 

Large  establishments  have  naturally  been  the  first 
to  develop  this  ^ industrial  medicine.''  Its  growth  is 
vividly  pictured  in  The  Modern  Hospital  for  August, 
1916,  and  its  technical  results  have  been  described  in 
many  professional  articles,  some  of  which  are  indicated 
in  the  bibliography.  Without  doubt  there  exists  a 
great  future  for  the  industrial  physician  and  industrial 
public  health  nurse,  co-ordinated  through  the  indus- 
trial clinic. 

The  technical  equipment  and  organization  of  in- 
dustrial clinics  is  of  course  similar  to  that  of  clinics  for 
medical  or  surgical  purposes  in  a  general  Dispensary. 
The  chief  obstacles  thus  far  encountered  to  further 
extension  are:  (1)  the  expense,  which  usually  is  paid 
by  the  employer,  and  (2)  the  objection  on  the  part  of 
the  employees  to  physical  examination.  Industrial 
clinics  may  exist  without  any  requirement  that  there 
be  medical  examination  of  employees.  The  workers 
often  fear  that  medical  examination  may  be  used  by 
an  employer  as  an  excuse  for  discharging  an  employee, 
or  penalizing  him  for  activity  in  trade  unions  or  other- 
wise.    This  is  a  problem  of  industry  and  not  of  public 


PUBLIC   HEALTH   DISPENSARY  313 

health  or  medicine.  Certainly  the  full  benefits  of 
skilled  medical  work,  preventive  and  curative,  through 
industrial  clinics,  can  only  be  realized  if  the  workers 
as  well  as  the  employers  have  a  share  in  the  responsi- 
bility and  the  management. 

Venereal  Clinics 

The  technique  of  clinics  for  syphilis  and  gonorrhea 
has  been  already  discussed.  The  extension  of  such 
clinics  is  part  of  a  militant  campaign  against  these 
diseases.  These  diseases  have  been  long  attacked  from 
the  standpoint  of  the  moralist.  More  recently  the 
public  health  attitude  has  come  to  the  fore.  The 
modern  Social  Hygiene  movement,  while  not  neglect- 
ing the  educational,  moral  and  other  relationships  of 
the  venereal  diseases  and  of  the  sex  problem,  has 
pushed  forward  the  health  aspect  as  one  of  the  chief 
elements  in  its  program.  Educational,  prophylactic 
and  administrative  measures  against  syphilis  and 
gonorrhea  are  necessary,  but  measures  for  their  prompt 
and  efl&cient  treatment  must  also  be  provided  on  an 
adequate  scale.  The  system  of  clinics  devised  in  the 
Scandinavian  countries  has  been  made  known  in  this 
country  particularly  by  Flexner's  book,  and  has  ex- 
ercised a  substantial  influence.  More  recently,  the 
Report  of  the  British  Royal  Commission  on  Venereal 
Diseases  has  led  to  a  well-worked-out  program  for  the 
prophylaxis  and  treatment  of  syphilis  and  gonorrhea 
in  Great  Britain.  An  extensive  system  of  clinics  is 
part  of  the  scheme.  The  War  has  advanced  this  pro- 
gram enormously  in  Great  Britain  and  in  the  United 


314  DISPENSARIES 

States,  to  an  extent  which  would  hardly  have  been 
believed  possible  a  few  years  ago. 
j  Laboratory  facilities  for  the  Wassermann  test  and 
for  the  diagnosis  of  gonorrhea,  have  been  made  ac- 
;  cessible  to  the  whole  medical  profession  in  many  lo- 
l  calities  by  the  State  or  City  Department  of  Health. 
I  Diagnostic  clinics,  at  which  patients  may  present 
'  themselves  for  examination,  and  a  report  be  sent  to 
their  physicians,  have  also  been  established,  as  in  New 
York.  Valuable  as  these  facilities  are,  they  can  go 
only  a  little  way.  Syphilis  and  gonorrhea  are  infec- 
tious diseases.  They  are  highly  prevalent.  Their 
treatment  by  efficient  modern  methods  is  expensive. 
The  diagnosis  and  treatment  also  requires  special 
skill  on  the  part  of  the  physician  or  surgeon,  skill  that 
is  not  usually  possessed  by  the  general  practitioner. 
The  great  bulk  of  the  treatment  of  these  diseases  is 
ambulatory.  It  is  a  special  field  for  the  Dispensary 
rather  than  for  the  hospital,  the  proportion  of  bed 
cases  to  the  total  number  of  cases  requiring  treatment 
being  small.  The  cost  of  treatment  by  private  medi- 
cal practice,  and  the  limited  amount  of  special  skill 
available  for  the  diagnosis  and  treatment,  render  the 
development  of  treatment  clinics  for  syphilis  and 
gonorrhea  a  necessary  part  of  a  program  for  dealing 
with  these  diseases  effectively. 

Investigation  of  existing  Dispensaries  in  New  York 
City  revealed  the  fact  that  a  majority  of  the  venereal 
clinics,  a  few  years  ago,  were  poorly  equipped,  poorly 
managed  and  inefficient.  No  comparison  of  inefficient 
clinics  with  the  average  efficiency  in  private  practice 


PUBLIC   HEALTH   DISPENSARY  315 

has  been  available  or  could  easily  be  made.  The 
work  of  a  certain  small  number  of  clinics,  however,  ^ 
has  demonstrated  that  efficient  treatment  of  syphilis 
and  gonorrhea  in  dispensary  clinics  is  possible.  The 
equipment  and  technique  of  organization  and  manage- 
ment has  been  worked  out.  Efficient  treatment  in 
such  clinics,  even  if  the  medical  staffs  are  paid,  is 
relatively  economical  compared  with  the  minimum 
cost  of  skilled  care  in  private  treatment.  We  may 
anticipate  that  an  extensive  system  of  such  clinics  will 
be  instituted  in  the  near  future  in  many  parts  of  this 
country.  The  self-supporting  pay  clinic  for  syphilis 
and  gonorrhea  has  been  demonstrated  as  a  possibility 
and  is  likely  to  develop  somewhat.  But  the  general 
health  movement  will  insist  on  the  provision  of  facili- 
ties for  treating  syphilis  and  gonorrhea  under  condi- 
tions such  as  will  render  the  clinics  most  widely  ac- 
cessible. If  venereal  clinics  are  to  charge  nominal 
fees,  or  be  free,  the  expense  involved  will  necessitate 
public  rather  than  private  support. 

The  Health  Center 

We  might  trace  the  rise  of  other  public  health  move- 
ments which  have  led  to  the  establishment  of  special 
clinics, — dental  clinics  or  inebriety  chnics,  for  ex- 
ample. But  it  will  be  sufficient,  after  our  review  of 
several  different  types  of  public  health  Dispensaries, 
if  we  summarize  their  common  qualities. 

1.  The  public  health  Dispensary  has  a  militant 
purpose.  It  is  not  merely  passive.  It  aims  to  get 
hold  of  cases  of  disease,  or  to  get  into  touch  with  people 


316  DISPENSARIES 

who  are  likely  to  contract  disease.     It  aims  to  prevent 
as  well  as  to  cure. 

2.  The  typical  public  health  Dispensary  is  local  in  its 
reach.  This  is  partly  because  preventive  work  must 
be  brought  closer  to  people  than  work  that  is  primarily 
curative,  and  partly  because  more  effective  educa- 
tional work  can  be  done  when  the  personal  relation- 
ships between  doctors,  nurses  and  patients  are  em- 
phasized. This  can  best  be  done  by  neighborhood 
connection. 

3.  The  public  health  nurse  is  a  characteristic  com- 
mon factor.  She  is  the  field  agent  in  the  preventive, 
educational  and  curative  work  of  all  forms  of  public 
health  clinics. 

Every  one  of  the  chief  public  health  movements  of 
recent  years  has  given  rise  to  a  special  group  of  public 
health  clinics.  Each  of  these  public  health  movements 
has  developed  as  the  result  of  the  special  interest  of  a 
particular  group  of  people, — the  doctors  and  the  lay- 
men particularly  concerned  with  tuberculosis,  the 
pediatricians,  the  psychiatrists.  Each  of  these  public 
health  movements  and  its  clinics  has  developed  a 
special  technique  and  has  trained,  or  tried  to  train,  a 
special  group  of  doctors  and  nurses  to  carry  out  the 
technique  effectively. 

So  far,  so  good.  During  the  period  wherein  these 
different  pubUc  health  movements  have  been  growing 
and  experimenting,  in  order  to  decide  upon  the  methods 
that  will  yield  the  best  results  with  their  particular 
problem,  such  development  of  technique  along  special- 
ized lines  was  undoubtedly  necessary.     But  since  these 


PUBLIC  HEALTH  DISPENSARY  317 

movements  are  local  in  application,  particularly  as 
regards  clinics  and  visiting  nurses,  a  number  of  sepa- 
rate groups  of  doctors  and  nurses  must  work  with  people 
in  the  same  district  and  visit  homes  within  the  same 
area.  The  question  naturally  arises  whether  some 
combination  of  administrative  or  field  staff  could  not 
be  made  of  the  different  clinics  in  a  district;  also 
whether,  if  a  number  of  different  doctors  and  nurses 
are  dealing  with  the  same  family  at  the  same  time,  for 
several  special  purposes,  there  is  not  some  risk  that 
families  may  suffer  from  educational  confusion.  The 
advance  of  the  campaigns  against  tuberculosis,  infant 
mortahty,  diseases  of  school  children,  etc.,  has  been 
rapid.  For  that  very  reason,  each  public  health 
movement  must  now  face  the  problems  of  co-ordina- 
tion as  well  as  the  pleasures  of  growth. 

In  the  early  stages  of  these  movements,  when  local 
clinics  were  started  and  doctors  and  public  health 
nurses  were  set  at  work,  the  basic  idea  was  service  in 
a  specialty, — tuberculosis,  pediatrics,  dentistry,  etc. 
The  specialty  was  the  unit.  Now  another  conception 
is  beginning  to  dominate, — the  population  unit:  service 
to  all  the  people  within  a  defined  district.  A  new  test 
of  work  has  therefore  arisen, — the  One  Hundred  Per 
Cent  Idea.  In  its  beginnings,  the  anti-tuberculosis 
movement  tried  to  get  hold  of  whatever  tuberculosis 
cases  it  could.  Results  were  measured  by  what  was 
accomplished  for  these  cases.  Later,  after  the  problem 
had  been  more  deeply  studied,  a  new  aim  was  defined :  to 
ascertain  the  number  of  tuberculosis  cases  in  the  com- 
munity, and  in  each  district;  then  to  reach  all  these 


318  DISPENSARIES 

cases,  or  at  least  to  estimate  the  results  of  the  work 
in  terms  of  all  the  cases  which  should  have  been  reached. 

So  the  infant  welfare  movement  began  with  such 
babies  as  came  to  its  clinics  and  ^^milk  stations"; 
later  it  advanced  to  reckoning  the  total  number  of 
babies  in  the  district,  and  aiming  to  reach  them  all. 
To  have  a  special  set  of  school  doctors  and  nurses, 
another  set  of  infant  welfare  doctors  and  nurses,  still 
another  of  obstetrical  and  ^^ prenatal'^  doctors  and 
nurses,  and  so  on, — all  working  in  the  same  area,  all 
visiting  in  the  homes  in  the  same  area, — raises  the 
question  as  to  whether  the  organization  cannot  be 
simplified.  The  diagnostic  ability  of  a  specialist  in 
tuberculosis  or  pediatrics  may  be  required  in  the  clinic 
for  certain  cases.  But  in  carrying  out  educational 
work  in  the  home,  cannot  a  single  properly  trained 
visiting  nurse  serve  several  doctors?  Cannot  duplica- 
tion of  plant  and  administrative  service  be  avoided? 
Cannot  the  broad  unity  of  all  forms  of  public  health 
work  be  emphasized  visibly  before  the  eyes  of  a  district? 

The  Health  Center  Idea  is  the  answer  to  this 
question.  The  Health  Center  is  based  on  two  main 
principles:  first,  the  population  unit;  second,  local 
co-ordination.  The  Health  Center  Idea  may  be  said 
to  mean :  doing  things  for  everybody,  and  doing  things 
together,  within  a  given  district.  More  specifically, 
it  is  public  health  work  which  involves 

1.  A  population  unit,  i.e., 

(a)  The  area  and  population  covered  is  defined ; 

(b)  The  aim  is  to  reach  all  the  population  so  far  as 

the  health  services  offered  apply; 


PUBLIC   HEALTH   DISPENSARY  319 

(c)  The  results  are  measured  by  the  one  hundred 
per  cent  test,  that  is,  not  the  number  of  per- 
sons reached  effectively,  but  the  proportion 
of  the  population  which  is  reached  effectively. 

2.  The  co-ordination  of  local  effort,  especially, 

(a)  Of  the  medical  and  sanitary  services  within  the 

district; 

(b)  Of  the  nursing  services,  involving  correlation 

or  combination  of  various  nursing  specialties; 

(c)  Of    social   services,    involving    correlation    or 

combination  of  neighborhood  forces,  and  of 
the  social  agencies  at  work  in  the  neigh- 
borhood ; 

(d)  The  local  headquarters  and  clinics  of  all  forms 

of  public  health  work  for  a  district  to  be 
within  a  single  building. 

3.  A  local  administrative  unit,  involving, 

(a)  A  local  administrative  head; 

(b)  Supervision  of  all  special  services  by  special- 

ists working  administratively  through  the 
local  head. 

Bringing  different  health  services  together  in  a 
single  building  is  in  itself  an  indirect  means  of  co- 
ordinating them.  Co-operation  is  promoted,  almost 
enforced;  co-ordination  is  suggested  and  facilitated. 
Bringing  all  the  health  activities  under  a  single  ad- 
ministrative control  in  the  same  building  for  a  district 
takes  us  much  farther  still. 

A  general  sense  of  need  for  co-ordination  of  local 
health  movements  has  led  to  a  variety  of  Health 
Centers.  Some  incorporate  only  a  few  of  all  the 
principles  above  enumerated;  others  are  more  far- 


320 


DISPENSARIES 


reaching  and  complete.  The  Health  Center  estab- 
lished in  1915  by  Dr.  S.  S.  Goldwater,  then  Health 
Commissioner  of  New  York  City,  was  comprehensive 
in  character,  as  the  following  outline  shows : — 

HEALTH  DISTRICT  NO.  1— NEW  YORK  CITY  HEALTH 

DEPARTMENT 


Functions  Performed 

1.  Prenatal  work 

2.  Infant's  milk  sta- 

tion 

3.  Examination     of 

children,     pre- 
school age 

4.  Medical    inspec- 

tion  of  school 
children 

5.  Supervision       of 

midwives    and 
fomidlings 

6.  Tuberculosis  sup- 

ervision 


7.  Other    infectious 

diseases 

8.  Food  inspection 

9.  General     sanita- 

tion 
10.  Public  health  edu- 
cation 


District  Staff 
Health  Officer  of  Dis- 
trict (part  time) 
In  full  local   adminis- 
trative charge 
Medical  Inspector  (part 
time)  Fimctions  2,  3, 
4 


Three    nurses,    Func- 
tions   1-7 

One  Nurse's  Assistant, 
Function  2 


Food   inspector    (part 

time) 
Sanitary     inspector 

(part  time) 


Supervising  Staff 

Health    Commissioner 

or 

Deputy 


Bureau  Chiefs  of 

1.  Child  Hygiene 

2.  Preventable      Dis- 
eases 

3.  Food  Inspection 

4.  Sanitation 

5.  Public  Health  Edu- 
cation 


This  single  center  was  established  as  a  model  or  as  an 
experiment  and  the  health  work  in  the  remainder  of  the 
city  was  not  thereby  changed. 

In  contrast  to  the  method  employed  in  New  York, 
Cleveland  has  approached  the  problem  in  a  different 
way;  it  has  chosen  to  develop  the  health  center  idea 
evenly  throughout  the  whole  city.  The  city  of 
Cleveland  has  been  divided  into  eight  health  districts 


PUBLIC  HEALTH   DISPENSARY  321 

of  approximately  equal  population.  In  each  district 
there  has  been  established  a  central  office  or  health 
center.  Eventually  each  district  will  have  a  full-time 
physician  who  will  also  be  a  deputy  health  officer, 
but  as  yet  this  plan  is  only  partly  accomplished. 
Each  district  office  now  has  a  supervising  head  nurse, 
and  two  stenographers.  The  statistics  for  the  district 
are  collected,  tabulated  and  kept  in  these  district 
offices.  Each  district  is  divided  into  eight  to  ten  sub- 
districts  in  each  of  which  is  one  nurse  responsible  to 
the  supervising  nurse  of  the  district.  Each  nurse  now 
carries  out  in  her  sub-district  the  following  lines  of  work : 

(1)  Contagious  disease;  (2)  child  hygiene;  (3)  tu- 
berculosis; (4)  some  supervision  of  parochial  school 
pupils;  (5)  general  sanitation,  housing,  etc.  In  one 
district  some  general  home  nursing  is  done,  but  in  the 
other  districts  the  Visiting  Nurse  Association  (a 
voluntary  organization)  carries  on  this  branch  of  the 
work.  In  the  near  future  it  is  planned  to  add  to  these, 
venereal  disease  and  prenatal  work. 

In  each  district  there  is  maintained  a  tuberculosis 
Dispensary  at  the  health  center  and  also  a  babies^ 
prophylactic  Dispensary.  Sick  babies  are  referred  to 
the  family  physician  or  to  the  central  clinic  of  the 
Babies'  Dispensary  and  Hospital.  It  is  planned  to  add 
soon  prenatal  clinics  and  prophylactic  and  advisory 
clinics  for  venereal  diseases.  For  active  treatment 
venereal  cases  will  be  referred  to  established  treat- 
ment Dispensaries.  These  clinics  are  manned  partly 
by  full-time  city  physicians  and  partly  by  part-time 
physicians  under  the  direction  of  the  bureau  chiefs. 


322  DISPENSARIES 

In  the  central  office,  acting  as  supervisors  of  the 
district  dispensary  work  and  as  the  cabinet  for  the 
health  commissioner,  are  expert  bureau  chiefs. 

It  has  been  recognized  that  private  or  voluntary 
organizations  are  necessary  not  only  to  establish  the 
work  and  to  demonstrate  its  claim  for  municipal  sup- 
port, but  to  keep  progressive  investigating  organiza- 
tions in  existence.  One  district  of  Cleveland  has  there- 
fore been  turned  over  to  voluntary  organizations,  in- 
cluding Western  Reserve  University,  but  the  records 
of  this  district  are  kept  uniform  with  the  other  dis- 
tricts. By  giving  over  one  district  to  the  voluntary 
organizations,  it  is  planned  to  keep  these  organizations 
alive  and  active  and  give  them  opportunity  to  develop 
any  new  or  better  methods  or  to  carry  out  any  form  of 
sociologic  research.  The  district  operated  by  the 
voluntary  agencies  is  known  as  the  ''University'^ 
district  and  it  is  used  by  the  University  for  all  practical 
and  field  work  of  its  classes  in  sociology,  public  health 
nursing,  etc.  It  is  planned  that  the  bureau  chiefs 
shall  be  University  instructors,  which  will  connect  the 
health  department  not  only  with  the  social  courses  of 
the  University,  but  also  with  the  Medical  School. 

Beginning  with  1917  the  mortality  and  morbidity 
records  will  be  tabulated  on  the  basis  of  these  districts 
so  that  the  public  health  of  the  eight  districts  may  be 
separately  compared  and  considered.  Many  volun- 
tary organizations  are  still  doing  special  work  for 
people  residing  anywhere  in  Cleveland,  but  more  and 
more  this  work  is  becoming  in  nature  supplementary 
to  the  work  of  the  health  centers  or  districts. 


PUBLIC   HEALTH   DISPENSARY  323 

The  Buffalo  Department  of  Health  has  a  chain  of 
Health  Centers  in  which  certain  clinics  do  not  only- 
preventive  work,  but  curative  also.  In  Dayton, 
Ohio,  combination  of  nursing  services  has  taken  place, 
the  staff  of  the  Health  Department  and  of  the  private 
Visiting  Nursing  Association  being  pooled  under  a 
single  administrative  head.  Movements  in  this  direc- 
tion in  many  other  cities  might  be  described.  Health 
Centers  established  by  private  organizations,  as  in 
Philadelphia,  have  been  taken  over  by  the  city.  The 
participation  of  the  people  of  the  district  in  the  manage- 
ment or  support  of  the  local  health  services  has  also 
been  urged,  as  in  the  Health  Center  of  the  Bowling 
Green  Neighborhood  Association,  New  York  (origi- 
nally founded  by  the  New  York  Milk  Committee), 
and  in  the  far-reaching  plan  for  a  district  Social  Unit 
Organization,  now  developing  in  Cincinnati  under 
Mr.  and  Mrs.  Wilbur  C.  Phillips.  Many  and  varied 
illustrations  of  the  Health  Center  idea  are  now  arising 
all  over  the  country. 

The  extent  to  which  a  visiting  nurse  can  efficiently 
perform  various  public  health  functions  is  perhaps  a 
question.  It  must  be  borne  in  mind  that  educational 
work,  whether  in  connection  with  a  case  of  tuberculosis 
or  infant  welfare,  is  much  the  same  in  its  broad  human 
relationships.  Certain  technical  procedures  must  be 
mastered  but  these  are  simple.  They  must  be  simple, 
else  patients  or  mothers  will  not  grasp  them.  The 
problem  of  maintaining  adequate  technical  standards 
in  tuberculosis,  baby  welfare,  or  other  forms  of  visiting 
nursing  service,  when  a  single  nurse  is  performing 


324  DISPENSARIES 

various  functions,  is  a  problem  of  training  in  the  first 
place,  and  of  supervision  in  the  second.  The  future 
will  help  to  solve  this  problem,  but  it  goes  without 
saying  that  to  prevent  the  multiplication  of  special 
services  in  a  district,  some  steps  must  be  taken. 

In  small  towns,  and  still  more  in  rural  communities, 
the  problem  sometimes  solves  itself,  because  visiting 
nursing  service  often  begins  with  a  single  nurse  who 
^^does  all  she  can."  Of  necessity  she  performs  a 
variety  of  functions.  In  any  community,  the  com- 
bination of  local  health  and  preventive  services 
within  a  single  building  for  each  district,  ought 
to  be  insisted  upon,  whether  the  organizations 
conducting  the  various  activities  are  public  or  private, 
or  both.  So  far  as  clinics  are  concerned,  there  are 
direct  economies  in  use  of  plant.  So  far  as  administra- 
tion and  nursing  services  are  concerned,  a  single 
building  by  no  means  implies  a  single  head  or  a  unified 
staff  of  nurses,  but  is  the  best  means  of  opening  the 
way  to  gradual  development  of  the  technique  of  local 
co-ordination  of  these  various  health  activities.  A 
single  Health  Headquarters  for  each  district,  moreover, 
brings  the  work  of  public  and  private  health  organiza- 
tions home  to  the  people  in  much  more  tangible  and 
impressive  fashion  than  is  possible  when  each  of  the 
different  activities  have  headquarters  scattered  over 
the  same  area.  They  tend  to  bring  before  the  minds 
of  the  people  not  only  Health  Services,  but  a  Health 
Ideal. 


PAY  CLINIC  325 


CHAPTER   XIX 

THE  SPECIAL  DISPENSARY  AND  THE  PAY 

CLINIC 

There  was  included  in  the  classification  of  Dispen- 
saries made  in  Chapter  III  a  small  group  of  Special 
Dispensaries,  confining  their  attention  to  a  single 
disease  or  a  group  of  closely  related  diseases.  The 
most  frequent  of  these  institutions  are  Dispensaries 
dealing  with : — 

The  Special  Dispensary 

Diseases  of  the  Eye 

Diseases  of  the  Ear,  Nose  and  Throat 

Diseases  of  the  Eye,  Ear,  Nose  and  Throat 

Children's  Diseases 

Orthopedics 

Gynaecology 

Neurology 

Psychiatry 

'^Skin  and  Cancer" 

Dentistry 

Certain  of  the  public  health  Dispensaries  which  were 
dealt  with  in  the  last  chapter  limit  their  work  to  some 
of  the  above  diseases,  but  these  are  not  included  here. 
The  large  Special  Dispensaries  of  course  exist  chiefly 
in  the  great  cities.  They  have  contributed  in  many 
instances  substantially  to  the  advancement  of  a 
specialty,  bringing  together  a  group  of  physicians  or 


326  DISPENSARIES 

surgeons  interested  in  a  particular  phase  of  medical 
work,  and  providing  excellent  equipment  for  the  ad- 
vancement of  specialist  technique.  Reference  to  the 
statistics  of  the  growth  of  Dispensaries  in  Chapter  III 
indicates  that  the  large  Special  Dispensary  has  not 
increased  in  numbers  nearly  as  fast  as  the  General 
Dispensary.  The  number  in  fact,  so  far  as  can  be 
ascertained,  is  probably  not  more  than  fifty  per  cent 
greater  today  than  fifteen  years  ago,  whereas  the 
number  of  General  Dispensaries  has  at  least  quad- 
rupled during  the  same  period. 

There  are  indeed  good  reasons  why  large  Special 
Dispensaries  are  not  to  be  encouraged  in  most  in- 
stances. Their  essential  weakness  consists  in  inability 
to  take  an  all-round  view  of  the  patient,  and  to  relate 
special  conditions  to  general  conditions.  All  the 
general  conditions,  for  example,  which  may  influence 
a  disease  of  the  eye,  or  which  may  be  influenced  by 
eye  diseases,  must  be  referred  to  another  institution 
for  treatment,  if  the  patient  presents  himself  at  a 
special  opthalmological  Dispensary.  From  the  strictly 
medical  standpoint,  moreover,  there  is  serious  dif- 
ficulty of  making  an  adequate  diagnosis  in  complex 
cases  due  to  the  lack  of  the  necessary  consultant  or 
specialists  within  the  institution.  Some  of  the  large 
Special  Dispensaries  have  in  a  measure  made  up  for 
this  by  establishing  a  group  of  consultants,  but  this 
effort  on  their  part  is  merely  a  recognition  of  the 
fundamental  principle  that  such  work  as  the  Specialist 
Dispensaries  have  attempted  would  be  better  done 
if  these  clinics  were  part  of  a  general  institution.     This 


PAY  CLINIC  327 

is  true  even  of  pediatric  Dispensaries  attached  to 
children's  hospitals,  although  a  number  of  such  in- 
stitutions have  built  up  for  themselves  complete 
consulting  staffs,  or  a  complete  set  of  specialist 
clinics  for  children,  so  that  they  are  in  fact  general 
Dispensaries  dealing  only  with  children.  The  peculiar 
problems  presented  by  mental  disease  render  such 
special  institutions  as  the  Phipps  Institute  in  Balti- 
more or  the  Psychopathic  Hospital  of  Boston'desirable 
as  research  centers,  if  nothing  else,  but  these  institu- 
tions must  and  do  provide  within  their  own  staffs 
for  the  necessary  specialists.  Much  further  develop- 
ment of  large  Special  Dispensaries  as  independent 
institutions  is  hardly  to  be  looked  for. 

We  have  already  seen,  however,  that  there  are  likely 
to  be  more  special  public  health  clinics  for  school 
children,  and  other  local  clinics  providing  specialist 
service  in  districts  or  communities  otherwise  un- 
provided for.  Special  treatment  clinics  should  be  so 
located  that  they  will  be  reasonably  accessible  to  the 
people  needing  their  services.  This  principle  of 
localization  must  be  carefully  worked  out  and  applied 
with  differing  force  to  different  specialties.  In  pro- 
portion as  the  need  for  a  certain  specialty  is  wide- 
spread, in  the  same  proportion  should  the  treatment 
cUnics  be  localized.  This  therefore  appUes  particu- 
larly to  dental  clinics.  Monumental  buildings  to 
which  all  the  children  of  a  city  are  supposed  to  be 
brought  for  prophylactic  and  curative  dental  service 
cannot  be  as  desirable  from  the  standpoint  of  benefit 
to  the  people  as  a  system  of  many  local  dental  clinics. 

22 


328  DISPENSARIES 

So  far  as  well-equipped  centers  for  dental  study  and 
research  are  concerned,  the  stronger  dental  schools 
ought  to  provide  this  in  sufficient  measure,  and  the 
clinics  established  primarily  to  provide  dental  service 
for  the  people  should  be  localized.  Much  is  also  to  be 
said  in  favor  of  combining  special  treatment  clinics 
with  the  Health  Centers.  Particularly  needed  are 
special  clinics  (for  school  children  and  adults)  dealing 
with  diseases  of  the  eye,  ear,  nose  and  throat,  and 
dental  clinics.  The  Health  Center  of  the  future  may 
well  be  also  a  Specialty  Center,  including  such  clinics 
as  those  for  tuberculosis,  babies,  prenatal  service, 
general  examinations  for  children,  and  the  various 
specialized  treatment  clinics  already  described.  If 
the  program  for  dealing  with  venereal  disease  follows 
in  the  United  States  the  same  course  which  it  is  taking 
in  Great  Britain,  clinics  for  treating  syphilis  and 
gonorrhea  will  be  localized  to  some  extent  and  will  be 
associated  with  a  certain  number  of  the  specialty 
centers  as  well  as  with  the  larger  central  medical  in- 
stitutions. 

The  expense  of  specialists'  service  at  the  rates  usu- 
ally charged  in  private  offices  has,  as  already  pointed 
out,  rendered  it  difficult  for  a  large  part  of  the  popula- 
tion to  secure  it  except  through  medical  institutions. 
A  large  part  of  specialist  service  is  out-patient  rather 
than  bedside  work.  It  is  noteworthy  that  in  many  of 
the  specialties  there  exist  not  only  physicians  treating 
the  disease  but  also  purely  commercial  ventures,  selling 
remedies  without  diagnosis.  Thus  opticians  provide 
glasses,  throwing  in  an  ^^examination''  free.     All  sorts 


PAY  CLINIC  329 

of  apparatus  for  relieving  deafness  can  be  bought  over 
the  counter.  The  orthopedist  must  compete  with  the 
purveyor  of  footplates,  braces,  elastic  stockings,  etc. 
A  great  variety  of  patented  and  unpatented  medicines 
are  offered  for  affections  of  the  throat  and  nose,  the 
nervous  system,  or  the  venereal  diseases.  If  the 
people  as  a  whole  are  to  understand  what  modern 
medicine  has  to  offer  and  are  to  reap  its  benefits,  then 
the  resources  of  modern  medicine,  including  the  spe- 
cialists when  necessary,  must  be  within  their  means. 
Otherv/ise  self-diagnosis  and  self-treatment  must  be 
the  main  resource  of  most  people,  particularly  in  the 
more  expensive  specialties. 

In  other  words,  it  is  of  particular  importance  that 
diagnosis  and  treatment  by  specialists  shall  somehow 
be  brought  more  within  the  reach  of  the  general 
public.  The  charitable  Dispensary  does  this,  but  the 
hours  at  which  the  charitable  clinics  have  usually 
been  held  are  not  convenient  to  working  people. 
They  are  generally  during  working  hours  and  there- 
fore involve  loss  of  time  and  wages.  Furthermore,  a 
large  number  of  people  do  not  wish  to  accept  medical 
charity,  or  to  enter  any  charitable  institution  and 
receive  that  for  which  they  make  no  corresponding 
return. 

The  Pay  Clinic 

The  Pay  Clinic  is  one  answer  to  the  problem  just 
stated.  While  Pay  Clinics  are  by  no  means  neces- 
sarily confined  to  the  specialties,  they  have  developed 
thus  far  chiefly  within  this  field,     A  Pay  Clinic  may  he 


330  DISPENSARIES 

defined  as  a  clinic*  in  which  a  fee  is  charged  patients 
corresponding  with  the  cost  of  the  service  rendered,  in- 
cluding compensation  for  the  physician.  A  Pay  Clinic 
must  aim  to  be  self-supporting,  although  this  need  not 
interfere  with  the  acceptance  of  certain  free  or  part- 
paying  patients,  any  more  than  a  doctor  in  private 
practice  refuses  such.  In  fact,  the  Pay  Clinic  is  or 
should  be  in  much  the  same  relation  to  the  patient 
and  to  the  community  as  the  doctor  who  supports 
himself  by  the  practice  of  medicine.  It  offers  a  service, 
not  a  charity;  it  expects  a  return  sufficient  to  render 
it  self-sustaining;  its  staff,  medical  and  lay,  must  re- 
ceive compensation,  in  money  and  opportunity,  suf- 
ficient to  attract  and  retain  them.  It  is  simply  the 
co-operative  practice  of  medicine  on  a  business  basis. 
We  see  this  exemplified  very  clearly  in  the  Mayo 
Clinic,  at  Rochester,  Minnesota.  Several  less  known 
organizations,  as  in  Los  Angeles,  are  following  the 
same  line.  At  the  other  extreme  of  worthiness  are 
disreputable  Pay  Clinics  run  by  questionable  physi- 
cians, or  quacks,  such  as  advertise  themselves  in  some 
cities.  Such  enterprises  are  rightly  frowned  upon, 
and  should  be  regulated  by  law,  because  the  merely 
commercial  exploitation  of  ill-health  for  private  profit 
is  against  public  policy.  The  maintenance  of  high 
scientific  standards  and  of  a  spirit  of  public  service, 
such  as  generally  characterize  individualistic  medical 
practice,  is  essential  in  Pay  Clinics  if  they  are  not  to 
be  merely  commercial  ventures.  Regulation  by  the 
proper   public   authority,    under   a   suitable   law   as 

*  Or  if  there  is  a  group  of  clinics,  we  may  speak  of  a  Pay  Dispensary. 


PAY  CLINIC  331 

proposed  in  Chapter  XXII,  is  desirable  for  all  Dis- 
pensaries whether  pay  or  charitable. 

The  Pay  Clinic  established  as  a  public  service  en- 
terprise or  '^ self-supporting  philanthropy,"  is  a  recent 
development.  Naturally  these  clinics  have  been 
opened  during  the  late  afternoon  or  the  evening  hours, 
inasmuch  as  they  aim  to  serve  wage-earners  to  whom 
the  usual  day-time  clinics  mean  loss  of  pay  and  some- 
times the  threatened  loss  of  a  job.  The  first  such 
clinic  was  for  Eye  Diseases,  instituted  at  the  Boston 
Dispensary  in  April,  1913.  The  same  institution 
opened  a  Genito-Urinary  Pay  Clinic  in  March  of  the 
next  year,  a  few  months  later  a  Syphilis  Pay  Clinic,  in 
1916  a  Nose,  Throat  and  Ear  Pay  Clinic,  and  in  1917 
a  Pay  Clinic  for  General  Medical  and  Surgical  diseases. 
The  Brooklyn  Hospital  opened  Pay  Clinics  for  syphilis 
and  gonorrhea  in  1915,  an  institution  in  Chicago  opened 
one  in  1916,  and  Lakeside  Hospital,  Cleveland,  a  sim- 
ilar clinic  in  1917.  At  the  time  of  this  writing  the 
Pay  Clinic  idea  appears  to  be  under  serious  discussion 
in  many  other  institutions. 

The  chief  differences  between  these  clinics  and  those 
which  we  have  already  studied  are  on  the  financial 
side.  At  the  Boston  Dispensary  patients  are  charged 
$1.00  for  the  first  visit,  50  cents  for  later  visits;  medi- 
cines, eye-glasses,  etc.,  being  extra,  priced  at  fees  some- 
what above  cost.  At  the  Pay  Clinics  of  the  Booklyn 
Hospital  the  fee  is  $1.00  a  visit,  but  medicines  (except 
salvarsan)  are  furnished  without  additional  charge. 
As  to  medical  compensation  the  chief  of  a  clinic  operat- 
ing three  evenings  a  week  is  salaried,  at  more  than  one 


332  DISPENSARIES 

of  the  institutions  mentioned,  at  the  rate  of  $1,000 
a  year,  the  assistants  at  half  this  amount,  or  less  in 
some  cases.  For  clinics  running  two  evenings  weekly 
the  chief  has  usually  received  $5  per  clinic.  One  Pay 
Clinic  has  not  paid  medical  salaries  but  instead  has 
given  to  the  staff,  as  a  group,  a  certain  share  of  the 
gross  income  of  the  clinic,  to  be  divided  as  the  staff 
determines.  Most  of  the  other  Pay  Clinics  have  fol- 
lowed the  plan  of  paying  definite  medical  salaries, 
which  seems  more  dignified  and  satisfactory. 

Several  Pay  Clinics  have  been  started  for  purposes 
of  diagnosis  only,  the  most  notable  being  that  at  the 
Massachusetts  General  Hospital,  begun  in  1915. 
This  was  closed  shortly  after  the  entrance  of  the 
United  States  into  the  War.  To  this  and  to  other 
diagnostic  clinics,  patients  can  be  admitted  only  when 
referred  by  a  physician,  who  requests  an  opinion  and 
report.  The  Massachusetts  General  Hospital  Diag- 
nostic Clinic  charged  a  flat  rate  of  five  dollars  to  the 
patient,  plus  certain  extras,  such  as  X-rays  when 
necessary.  There  are  obvious  limitations  upon  a 
clinic  which  confines  its  work  to  diagnosis  only  and  will 
not  undertake  treatment.  Its  value,  however,  is  also 
obvious,  providing  as  it  does  a  center  of  organized 
equipment  and  organized  skill  which  would  otherwise 
be  rarely  accessible  to  the  mass  of  physicians  or 
patients  in  the  community.  The  development  of 
such  clinics  will  nevertheless  be  slow,  so  long  as  the 
mass  of  patients  are  not  informed  enough  to  demand 
them  and  the  mass  of  physicians  not  ready  enough  to 
trust  them.     The  possible  loss  of  a  patient  from  a 


PAY  CLINIC  333 

physician's  private  practice  is  a  serious  deterring  in- 
fluence against  sending  that  patient  to  a  diagnostic 
cUnic.  If  such  a  clinic  were  so  organized  as  to  be 
essentially  a  co-operative  association  of  a  large 
number  of  physicians,  this  difficulty  would  be  obviated 
and  the  service  of  the  clinic  greatly  broadened.  The 
purposes  of  a  diagnostic  clinic  can  be  fulfilled  by  a 
clinic  which  provides  treatment  in  the  usual  way,  but 
which  also  admits  patients,  on  request  of  a  physician, 
for  diagnosis  only,  pledging  to  send  them  back  to  their 
doctor  with  the  opinion  desired. 

The  equipment  and  management  of  Pay  Chnics 
need  no  special  attention  here.  The  sense  that  pa- 
tients are  paying  their  way  creates  a  somewhat  dif- 
ferent psychological  attitude  toward  them  on  the  part 
of  those  administering  the  medical  and  executive  work 
of  the  clinic.  More  individual  attention  and  greater 
dignity  for  the  patient  follow  as  a  natural  result. 
Where  Pay  Clinics  and  free  clinics  (or  clinics  with 
nominal  fees)  are  maintained  in  the  same  building  at 
different  hours,  there  is  a  considerable  problem  of 
shifting,  in  both  directions.  A  man,  for  example,  who 
has  been  out  of  work,  and  attending  the  day-time 
clinic,  secures  a  job  and  at  once  desires  to  attend  the 
Pay  Clinic,  held  at  hours  which  do  not  interfere  with 
his  daily  work  or  wage.  Conversely,  the  loss  of  a  job 
may  cause  a  shift  in  the  opposite  direction.  The 
record  system  of  the  pay  and  free  clinics  within  the 
same  institution  should  therefore  be  integrated,  that  is, 
be  conducted  as  one  system,  just  as  are  the  records  of 
the  different  clinics  of  the  free  Dispensary.    Then, 


334  DISPENSARIES 

whether  or  not  the  medical  staff  of  the  two  sets  of 
clinics  is  the  same,  the  physician  of  the  Pay  Clinic  will 
see  all  the  records  made  in  the  corresponding  free 
clinics  at  the  time  of  the  patient's  transfer  to  the  pay 
side;  and  vice  versa. 

The  Pay  Clinic  may  be  appraised  from  three 
aspects,  those  of  the  institution,  of  the  doctor  and  of 
the  public. 

The  Pay  Clinic  and  the  Public 

1.  From  the  standpoint  of  the  public,  consider  first 
the  specialty  of  opthalmology.  If  anything  is  the 
matter  with  our  eyes,  or  if,  for  instance,  we  need 
glasses,  we  can  secure  attention  from  one  of  several 
sources:  (1)  an  oculist  at  his  private  office;  (2)  a 
clinic  connected  with  a  medical  institution,  where  the 
patients  meet  the  oculist  instead  of  at  his  office;  (3) 
an  optician  or  optometrist,  who  will  test  the  eyesight 
and  provide  glasses,  if  he  persuades  the  patient  that 
glasses  are  needed;  (4)  the  shop,  selling  eye-glasses 
over  the  counter  without  examination  of  the  eyes. 
One  has  merely  to  try  on  various  pairs  until  one  finds 
a  pair  which  suits. 

The  cost  of  these  four  facilities  varies  widely. 
Assuming  that  we  require  eye-glasses,  which  is  the  most 
common  reason  why  people  seek  care  for  the  eyes,  the 
cost  of  the  oculist's  services  and  of  the  eye-glasses  will 
be  from  $8.00  to  $25.00,  according  to  his  reputation 
and  the  kind  of  glasses  purchased.  At  a  clinic,  as- 
suming that  merely  nominal  fees  are  charged  and  the 
glasses  are  sold  at  about  cost,  the  cost  would  be  from 


PAY  CLINIC  335 

$1.50  to  $4.00  or  $5.00.  The  optometrist  or  optician 
will  charge  a  patient  from  $2.00  to  $10.00.  The  price 
supposedly  includes  glasses  only,  the  examination 
being  nominally  free.  At  the  shop,  eye-glasses — such 
as  they  are,  may  be  purchased  over  the  counter  for 
from  10  cents  up  to  $1.00  or  more  per  pair.  Thus  the 
scale  ranges  from  $25.00  down  to  10  cents  as  the  cost 
of  a  pair  of  eye-glasses  fitted,  more  or  less,  to  the  wearer. 
We  pay  our  money  and  take  our  choice. 

Such  is  the  actual  economic  situation.  What  is  the 
social  result?  The  ideal  would  be  the  services  of  a 
skilled  oculist  for  every  person  needing  any  care  for 
the  eyes;  but  the  price  is  too  high  and  the  price  must 
remain  high  because,  in  private  practice,  an  oculist 
cannot  live  unless  he  charges  such  fees.  A  well- 
trained  man  must  make  his  living  by  charging  these 
rates  to  that  small  section  of  the  community  which  can 
afford  them.  The  remainder  of  the  community  is 
not  ordinarily  reached  by  such  services.  The  number 
of  individual  oculists  is  scanty  and  when  unorganized 
is  necessarily  too  high-priced.  The  optometrist  or 
optician,  or  the  shop  selling  eye-glasses  over  the 
counter,  ought  not  to  exist  at  all  except  under  the 
supervision  of  medical  men;  for  eyesight  is  too  pre- 
cious to  be  spoiled  by  the  meddling  of  inadequately 
trained  hands.  The  remedy  is  to  organize  the  medical 
service.  This  means  to  establish  clinics.*  We  have 
such  clinics,  but  they  are  supposed  to  be  only  for  the 
poor.     The  people  who  cannot  pay  $8.00,  $10.00  or 

*  This  does  not  mean  eliminating  the  optician,  whose  services  can 
and  should  be  utihzed  in  such  an  organization. 


336  DISPENSARIES 

$20.00,  but  who  would  pay  $3.00,  $4.00  or  even  $5.00, 
if  they  knew  they  were  getting  good  service,  and  who 
often  pay  similar  amounts  to  opticians,  are  left  in 
the  lurch.  They  cannot  get  skilled  medical  service 
for  the  eyes.  These  middle-class  people  are  the 
majority  in  every  community. 

Take  another  special  field:  Venereal  Diseases. 
From  the  standpoint  of  the  public,  there  are  four 
kinds  of  treatment  for  syphilis  and  gonorrhea,  namely : 

1.  Private  medical  practice. 

2.  Hospitals  and  Dispensaries,  chiefly  the  latter. 

3.  Quacks,  or  so-called  ''Medical  Institutes." 

4.  Treatment  by  patients  themselves,  usually  with 
medicines  or  apparatus  bought  at  drug  stores.  We  may 
call  this  last  self-treatment. 

Quack  treatment  and  self-treatment  are  undesirable 
facilities.  They  should  be  limited,  and,  if  possible, 
abolished.  We  can  diminish  the  amount  of  quack 
treatment  considerably  by  prosecuting  individuals 
and  by  preventing  quack  advertising;  but  while 
we  are  diminishing  the  amount  of  treatment  by  quacks, 
we  must  open  up  more  of  the  desirable  facilities  for 
treatment  and  make  them  accessible  to  more  people. 
Otherwise,  shutting  down  on  the  quacks  will  merely 
increase  the  already  vast  amount  of  self-treatment. 
In  studies  made  of  patients  applying  at  the  Boston 
Dispensary  Genito-Urinary  Pay  Clinics,"  including 
three  series  of  cases  totalling  about  five  hundred  in 
number,  it  was  found  that  previous  to  coming  to  the 
clinic  (for  gonorrhea)  twenty  per  cent  had  been  to 
private  physicians,  usually  leaving  because  they  had 


PAY   CLINIC  337 

no  more  money ;  ten  to  fifteen  per  cent  had  previously 
been  in  other  hospitals  and  Dispensaries;  about  twenty 
per  cent  had  been  to  quacks,  and  about  one-third  had 
depended  on  self -treatment.  The  remaining  propor- 
tion had  had  no  previous  treatment,  mostly  coming 
with  fresh  infections.  Thus,  fifty  per  cent  and  more 
of  these  cases  of  gonorrhea  had  had  no  reputable 
medical  attendance  previous  to  coming  to  the  clinic, 
and  the  successful  treatment  of  their  disease  had  been 
delayed,  in  some  instances  materially  hindered,  there- 
by. 

From  the  standpoint  of  cost  of  treatment,  syphilis 
and  gonorrhea  are  expensive  diseases.  Treatment  of 
either  syphilis  or  gonorrhea,  during  the  first  six  months, 
according  to  methods  followed  by  physicians  who  are 
regarded  as  experts  in  these  diseases,  would  cost  fully 
$200.00,  if  the  usual  rates  of  such  physicians  were 
charged,  or  somewhat  over  $100.00  if  the  same 
methods  were  pursued,  but  the  office  rate  of  the  general 
practitioner  were  in  effect.  The  cost  of  medicines  is  a 
large  additional  item,  since  at  drug-store  prices  be- 
fore the  War  these  would  have  amounted  to  $2.00 
a  week,  or  more.  All  these  are  minimum  rather 
than  maximum  figures.  Not  more  than  one  family 
in  ten  has  an  annual  income  of  over  $1,200.00,  and 
the  average  wage  of  the  individual  wage-earner  does 
not  exceed  half  of  that  amount.  Out  of  such  incomes 
the  expense  of  adequate  private  medical  treatment  for 
sj^hilis  and  gonorrhea  cannot  be  met.  Treatment 
is  begun  but  often  discontinued  because  the  financial 
burden  is  too  heavy.     Hence  there  is  a  large  field  here 


338  DISPENSARIES 

for  clinics.  For  certain  considerable  groups  in  the 
community,  the  pay  clinic,  rather  than  the  charity 
clinic,  is  desirable. 

In  the  wider  field  of  general  medicine,  suppose  we 
picked  ten  sick  people  at  random,  paying  no  attention 
to  '' social  classes. ''  To  provide  adequate  medical 
care  for  the  needs  of  these  people  might  cost  $5.00  in 
the  case  of  one,  $500.00  in  the  case  of  another,  and 
perhaps  the  man  who  had  only  the  $5.00  purse  might 
have  the  $500.00  disease!  At  any  rate,  the  cost  of 
adequate  medical  care  would  often  be  far  beyond  the 
patient's  means,  even  in  the  cases  of  people  who  do  not 
ordinarily  think  of  going  to  Dispensaries. 

Now,  the  public  can  be  divided  into  three  groups 
from  this  standpoint.  First,  those  who  can  pay  any- 
thing for  what  they  need:  the  rich;  second,  those 
who  can  pay  nothing,  or  practically  nothing:  the 
poor;  and  third,  those  who  can  pay  something,  who 
are  most  of  us.  Those  who  can  and  will  pay  some- 
thing are  by  far  the  largest  class  in  the  community, 
and  how  big  that  class  is,  and  how  big  the ''  something'' 
which  they  can  pay,  is  the  important  question.  But 
it  cannot  be  answered  offhand,  nor  can  it  be  answered 
in  general  terms,  for  the  problem  has  too  many  ele- 
ments in  it; — number  of  people,  age,  occupation,  in- 
come, medical  needs,  cost  of  medical  service  and  in- 
stitutional resources  of  the  community — all  have  to  be 
studied. 

Those  who  can  pay  something  for  medical  service 
but  who  cannot  meet  any  serious  emergency,  or 
any  long-continued  drain,  are  the  class  in  the  com- 


PAY  CLINIC  339 

munity,  who  at  the  present  day  get  the  poorest  medical 
service.  In  communities  where  hospital  and  dis- 
pensary service  have  been  well  developed  the  poor  are 
provided  for,  largely  through  the  same  physicians  who 
serve  the  rich.  But  the  middle  group  of  the  commu- 
nity is  not  to  be  reached  by  the  ordinary  clinic;  and 
to  meet  the  need  of  this  middle  group  is  the  function 
of  the  pay  clinic. 

The  Pay  Clinic  in  Relation  to  the  Doctor 

2.  Let  us  now  consider  the  Pay  Clinics  from  the 
standpoint  of  the  physician.  On  the  financial  side, 
it  is  essential  to  bear  in  mind  that  the  fees  received  by 
the  physicians  in  private  practice  are  a  gross  and  not  a 
net  income.  When  a  physician  works  in  his  private 
office,  the  rent,  the  equipment,  the  nurse  and  other 
assistants,  the  lighting,  heat,  records,  and  the  doctor's 
automobile,  must  all  be  paid  for.  When  the  physician 
works  in  a  Dispensary,  all  the  plant,  equipment  and 
attendants  are  provided.  Out  of  the  gross  income  of 
a  physician  in  private  practice  in  a  large  city,  a  not 
unreasonable  estimate  indicates  that  half  goes  to  meet 
the  expenses  of  the  doctor's  business,  leaving  only 
half  as  a  net  income  for  the  support  of  the  physician 
and  his  family.  There  are  of  course  instances  where 
the  percentage  would  be  lower,  others  where  it  would 
be  higher,  but  on  the  whole,  referring  at  least  to  medi- 
cal practice  in  cities,  it  is  believed  that  a  fifty  per  cent 
estimate  is  not  too  high. 

The  physician  in  the  Pay  Clinic  must  therefore  bear 
in  mind  that  the  salary  which  he  receives  for  his  service 


340  DISPENSARIES 

in  the  clinic  is  a  net  income.  If  a  physician  were 
employed  at  full-time  service,  at  the  rate  of  S5.00  for  a 
two-hour  clinic  and  were  actually  engaged  at  this  rate 
for  a  total  of  seven  hours  a  day  altogether,  he  would 
receive  compensation  at  this  rate  amounting  to 
$5,250.00  a  year  as  his  net  income,  this  being  equiva- 
lent to  a  private  '^ practice"  of  $10,500.00  annually. 
The  illustration  is  not  given  to  suggest  that  physicians 
be  engaged  in  this  fashion,  but  merely  to  indicate  the 
financial  basis  of  medical  salaries  in  Pay  Clinics  and  to 
point  the  contrast  between  the  gross  income  of  private 
practice  and  the  net  income  of  such  salaries.  Nor 
need  any  loss  of  dignity  be  consequent  upon  the  service 
of  the  physician  in  a  Pay  Clinic,  any  more  than  upon 
the  part  of  a  professor  in  the  faculty  of  a  university. 

Sometimes  there  has  been  said  to  be  an  undesirable 
competition  between  private  practice  and  Pay  Clinics. 
If  the  preceding  analysis  of  the  relation  between  the 
cost  of  treating  diseases  in  a  Dispensary,  and  the 
circumstances  of  many  sufferers,  is  correct,  then  the 
Pay  Clinic  is  not  providing  treatment  for  those  who 
would  otherwise  secure  adequate  care  from  private 
practice.  The  salaries  received  by  physicians  in  Pay 
Clinics  should  exceed  and  probably  will  exceed  the 
amount  which  the  same  patients  would  pay  to  physi- 
cians were  the  Pay  Clinics  not  in  existence.  This  can 
be  demonstrated,  especially  where  medicines  or  ap- 
paratus have  to  be  purchased.  For  example,  in  the 
Boston  Dispensary  Genito-Urinary  Clinic,  or  Syphilis 
Clinic,  the  total  cost  to  the  patient  of  treatment  over 
an  average  period  is  not  greater,  and  is  often  less  than 


PAY  CLINIC  341 

the  amount  which  the  patient  would  have  to  pay  for 
the  drugs  alone  if  purchased  at  the  prices  charged  in 
drug  stores.  Yet  out  of  what  the  patient  pays,  fully 
half  is  paid  back  to  the  physicians,  and  this  amount,  if 
the  patient  had  not  had  the  clinic,  would  all  have  gone 
to  the  drug  store  or  the  quack. 

In  the  Boston  Dispensary  Eye  Clinic,  it  is  similarly 
true  that  the  usual  retail  prices  for  eye-glasses  alone 
are  greater  than  the  total  expense  of  the  admission  fee 
to  the  clinic  plus  the  glasses,  sold  at  the  slight  advance 
above  cost.  The  real  difficulty  raised  by  Pay  Clinics 
is  not  that  they  fail  to  turn  into  the  medical  profession 
as  much  income  as  would  ordinarily  go  from  the  same 
patients  to  the  medical  profession.  The  nub  of  the 
difficulty  is  rather  that  the  income  would  go  to  certain 
physicians  rather  than  to  certain  others.  A  wide- 
spread organization  of  Pay  Clinics,  bringing  in  large 
numbers  of  physicians,  as  directors  of  clinics  and  as 
assistants,  would  remove  the  last  objection.  The  cure 
for  the  competition  between  Pay  Clinics  and  private 
practice,  so  far  as  it  exists  at  all,  is  more  Pay  Clinics. 

The  Pay  Clinic  and  the  Dispensary 

3.  Finally,  we  may  look  upon  Pay  Clinics  from  the 
standpoint  of  the  Dispensaries  maintaining  them. 
The  following  table  shows  the  financial  results  from 
certain  Pay  Clinics  over  a  period  of  years,  comparing 
income  and  outgo: — 


342  DISPENSARIES 

BOSTON   DISPENSARY 

Running 
Period  of  Time  Covered        Expenses*    Income 

Eye  Clinic  April,  1913  to  Oct.,  1917        $2,877.64  $3,067.74 
Geni  to-Urinary 

Clinic  March,  1914  to  Oct.,  1917     16,291 .  54  22,282 .  24 
JSkin  and  Syphilis 

i     Clinic  Aug.,  1914  to  Oct.,  1917          3,341.44  4,820.30 
Nose,  Throat  and 

Ear  Clinic  Sept.,  1916  to  Oct.,  1917          1,458.48  1,523.80 

Pay  Clinics  treating  general  medical  cases  involve  a 
wide  variety  of  work  and  must  be  carefully  studied  out 
in  order  to  solve  the  problems  of  management  and 
finance.  Surgical  Pay  Clinics  will  in  the  future  be 
largely  compensation  clinics  of  the  kind  already  de- 
scribed, treating  industrial  accident  cases  and  paying 
their  staff  salaries  or  fees,  preferably  salaries,  in  due 
ratio  to  the  work  done. 

To  the  ordinary  Dispensary  doing  charitable  work, 
the  establishment  of  Pay  Clinics  opens  a  new  field,  a 
wider  clientele  and  avenue  of  public  service.  It  will  be 
found  that  the  reaction  of  the  Pay  Clinic  upon  the 
'^free  clinic"  is  favorable.  There  is  a  stimulus  to 
efficient  service,  rising  out  of  the  new  psychological 
relation  between  doctor  and  patient,  and  between  the 
doctor  and  the  institution. 

Pay  Clinics  versus  Free  Clinics 

The  maintenance  of  Pay  Clinics  outside  of  working 
hours  at  once  raises  the  question  of  those  patients  who 
can  ill  afford  to  lose  time  and  wages,  yet  who  have 
heavy  family  responsibilities  or  do  not  earn  enough  to 
meet  Pay  Clinic  fees.     Can  such  patients  be  taken  free 

*  Include  all  elements  of  actual  outlay,  but  not  an  allowance  for  over- 
head supervision,  rental  of  space,  or  insurance. 


PAY  CLINIC  343 

or  for  part  pay?  The  answer  to  this  question  cannot 
be  based  wholly  on  financial  grounds.  Is  it  possible 
to  have,  side  by  side  in  the  clinic,  patients  who  are 
paying  a  dollar  or  fifty  cents,  and  others  who  pay 
twenty-five  cents  or  nothing?  If  one  patient  learns 
of  the  other's  situation,  will  not  the  one  desire  ad- 
mission for  the  lower  fee,  especially  when  the  two 
patients  are  given  just  the  same  service? 

Evening  Pay  Clinics  and  evening  free  clinics  might 
be  run  on  the  same  evening  in  the  same  building,  at 
the  same  time  or  just  after  one  another.  But  could 
they  be  thrown  together  and  run  as  one?  Without 
doubt,  a  certain  proportion,  not  a  very  large  propor- 
tion, of  free  or  part  paying  patients  can  be  included 
among  the  paying  patients  of  a  Pay  Clinic,  but  it  is 
difficult  to  see  how  the  proportion  can  equal  or  exceed 
fifty  per  cent.  By  careful  administration  this  obstacle 
might  be  overcome,  but  under  ordinary  conditions,  in  a 
large  clinic,  the  possibility  of  such  a  combination  seems 
very  questionable.  There  is  a  further  objection 
where  a  Pay  Clinic  is  established  in  a  Dispensary  build- 
ing already  identified  as  a  charitable  institution,  be- 
cause there  are  groups  in  the  community  not  well 
situated  financially,  and  certainly  needing  the  treat- 
ment provided  by  a  Pay  Clinic,  who  would,  however,  be 
unwilling  to  go  to  an  institution  which  bore  the  ^Haint 
of  charity, ''  even  if  they  paid  their  way. 

Cooperative  Pay  Clinics 

Why  should  not  Pay  Clinics  be  established  by  a 
group  of  physicians,  coming  together  for  co-operative 

23 


344  DISPENSARIES 

work  and  having  their  offices  so  situated  that  joint 
equipment  can  be  arranged?  The  difficulty  in  these 
instances  will  usually  be  a  defective  centralized  ad- 
ministration. This,  as  our  analysis  of  dispensary  or- 
ganization and  management  has  shown,  is  vital  to  the 
best  co-operative  work  among  physicians,  and  to  the 
efficient  management  of  the  records,  laboratories,  etc. 
Where  a  group  of  physicians  actually  established  an 
organization  with  adequate  equipment  and  complete 
administrative  machinery,  the  difficulty  would  be 
overcome,  and  we  should  have  Pay  Clinics  like  the 
Mayo  Clinic,  which  the  rich,  the  well-to-do,  and  those 
of  very  small  means  might  all  attend.  In  the  case  of 
clinics  for  syphilis  and  gonorrhea  we  may  rather  expect 
that  these  diseases  will  pass  so  much  under  public 
control  (as  tuberculosis  has  done)  that  treatment  will 
be  provided  at  public  expense.  The  field  of  Pay 
Clinics  for  venereal  diseases  will  thus  be  restricted  if 
not  abolished,  although  a  clinic  supported  by  general 
taxation  is  a  Pay  Clinic  in  a  certain  sense,  if  so  ad- 
ministered as  to  receive  a  variety  of  social  classes 
and  not  merely  ^Hhe  poor.'^  In  general  medicine, 
however,  and  in  most  of  the  specialties,  there  would 
seem  to  be  a  considerable  future  field  for  Pay  Clinics, 
partly  as  divisions  of  general  Dispensaries  and  partly 
as  private  enterprises  of  groups  of  physicians.  The 
encouragement  of  Pay  Clinics  of  either  type  is  a  meas- 
ure of  progress  in  the  development  of  co-operative 
medical  practice  on  a  democratic  basis. 


THE  MEDICAL  PROFESSION  345 


CHAPTER   XX 
DISPENSARIES   AND   THE   MEDICAL  PROFESSION 

Are  Dispensaries  to  increase  or  decrease  in  numbers, 
scope  and  influence?  Are  they  to  provide  medical 
service  for  a  larger  proportion  of  the  population  than 
they  do  today?  What  is  to  be  their  future  relation  to 
the  medical  profession? 

The  answers  to  these  questions  depend  partly  upon 
the  growth  and  trend  of  medical  science  and  practice 
and  partly  upon  economic  conditions  in  society. 
These  factors  must  be  analyzed  separately.  In  this 
chapter  we  shall  treat  the  medical  factor;  in  Chapter 
XXI,  the  economic. 

The  Passing  of  the  **Family  Physician" 

1.  In  former  times  the  general  practitioner  was  the 
family  physician.  Today  the  general  practitioner 
remains,  but  the  family  physician,  treating  a  particu- 
lar family  continuously,  and  in  close  touch  with  all  the 
members,  has  almost  disappeared.  The  reasons  for 
this  frequently  discussed  and  often  regretted  change 
appear  to  be  partly  the  growth  of  specialization  in 
medicine,  and  partly  the  greater  mobility  and  com- 
plexity of  our  population  and  of  modern  life  itself. 

The  rise  of  speciahzation  in  medicine,  to  which  we 
have  so  often  referred,  is  responsible  for  taking  large 
fields  of  medical  service  out  of  the  province  of  the 


346  DISPENSARIES 

general  practitioner,  and  therefore  making  it  much 
more  difficult  for  any  one  physician  to  provide  integral 
medical  service  for  a  family.  This  is  the  case  to  a 
considerable  extent  even  in  small  communities,  and 
much  more  so  in  large  cities.  In  all  but  the  very 
small  communities  the  general  practitioners  do  little 
in  specialties  such  as  the  eye,  ear,  nose  and  throat, 
orthopedics,  gynaecology,  etc.  Those  who  need  treat- 
ment by  specialists  seek  them  out,  or  go  to  a  hospital 
or  Dispensary,  and  do  not  expect  such  service  from 
their  general  practitioner. 

On  another  side,  the  close  relationship  between  a 
physician  and  a  family  has  been  made  more  difficult 
because  of  the  less  stable  character  of  our  population. 
People  in  large  cities  frequently  change  their  residence, 
and  even  in  small  communities  move  about  much  more 
than  in  former  times.  The  old  neighborhood  rela- 
tionships have  largely  broken  up,  and  this  affects  the 
close  touch  of  a  physician  with  a  family.  Further- 
more, the  influx  of  numbers  of  immigrants  has  made 
our  population  heterogeneous.  The  new  peoples  have 
brought  few  physicians  of  their  own  races  with  them. 
The  young  men  of  their  race  enter  only  slowly  into  the 
medical  profession,  and  the  immigrants  have  had  to 
depend  largely  upon  native  physicians  already  in 
practice.  The  rise  of  a  family  physician  system 
among  such  immigrant  groups  was  hardly  to  be  ex- 
pected and  has  not  occurred,  even  where  the  financial 
condition  of  the  immigrants  was  such  as  to  enable 
them  to  employ  private  doctors. 


THE   MEDICAL  PROFESSION  347 

The  Increase  of  Specialization 

2.  Both  because  of  the  advance  in  specialization 
and  the  greater  heterogeneity  and  mobility  of  our 
population,  the  family  physician  system  has  broken 
down.  The  close  connection  between  one  doctor  and 
one  family  gave  to  the  physician  a  knowledge  of  family 
traits  and  conditions  in  a  degree  which  had  high  medi- 
cal as  well  as  human  value.  Can  this  loss  be  re- 
placed? The  general  practitioner  must  now  treat 
the  patient  largely  in  families  where  he  has  no  such 
long-founded  knowledge  and  he  must  compete,  as  he 
frequently  complains,  with  the  two  groups  which  have 
arisen  out  of  the  growth  of  modern  medicine, — the 
specialists  and  the  medical  institutions  (hospitals  and 
Dispensaries) . 

This  complaint  is  natural,  for  in  a  measure  it  is  true. 
But  the  competition  of  the  specialist  and  of  the  medi- 
cal institution  depends  much  less  upon  the  intent  of 
either  of  these  sinners,  than  upon  the  forces  which  have 
called  them  into  being  and  which  are  today  develop- 
ing them  with  unexampled  rapidity.  These  forces 
are  essentially  those  of  medical  science.  Medical 
knowledge  has  been  enormously  enlarged.  Medical 
and  surgical  technique  has  been  advanced  at  a  bewil- 
dering rate.  No  one  man  can  now  master  more  than 
a  fraction  of  the  existing  field  of  medicine.  Special- 
ization is  necessary.  The  physician's  power  to  diag- 
nose and  cure  disease  is  enhanced^  but  his  needs  for 
technical  equipment  are  also  increased  beyond  any- 
thing known  formerly.  The  expense  of  professional 
equipment  and  the  demand  for  special  skill  are  two 


348  DISPENSAEIES 

results  of  the  progress  of  medical  science  which  have 
had  major  effects  upon  the  character  of  medical  serv- 
ice, and  which  are  chiefly  responsible  for  bringing 
about  the  changes  above  described. 

Consider  some  illustrations  of  the  expensiveness  of 
modern  equipment.  A  stethoscope  is  within  the 
reach  of  every  physician.  An  apparatus  for  taking 
the  blood-pressure  costs  $25.00.  Many  a  young 
doctor  has  to  think  twice  before  investing  in  one.  A 
microscope  with  needed  attachments  costs  $75.00  to 
$100.00;  and  if  the  doctor  is  to  employ  it  for  many 
kinds  of  examinations,  he  needs  special  training  in  its 
use.  The  laboratories  of  Health  Departments  will 
help  the  doctor  out  in  many  tests,  chiefly  in  contagious 
diseases,  and  commercial  laboratories  will  do  whatever 
else  he  wants,  but  these  are  expensive  for  his  patient. 
A  cystoscope  is  necessary  for  the  diagnosis  of  many 
relatively  common  troubles,  but  this  instrument  is 
expensive,  and  special  skill  is  necessary  to  use  it  with- 
out danger  to  the  patient.  The  apparatus  and  train- 
ing requisite  for  stud^dng  the  gastric  or  intestinal  con- 
tents are  quite  out  of  the  reach  of  men  who  cannot 
spend  both  money  and  time.  An  X-ray  equipment 
means  an  investment  of  $1,000.00  to  $3,000.00,  and 
few  doctors  would  have  enough  cases  to  use  it  to  more 
than  a  fraction  of  its  capacity.  Such  apparatus  is  too 
expensive  to  lie  idle,  and  should  be  kept  in  full  use  by 
being  at  the  service  of  a  number  of  physicians.  These 
illustrations  could  be  multiplied. 

3.  What  has  been  said  concerning  equipment  is 
equally  true  with  respect  to  the  speciaUzed  skill  and 


THE  MEDICAL  PROFESSION  349 

training  now  needed.  This  applies  to  laboratory  work, 
X-ray  work,  and  to  the  use  of  various  instruments 
for  general  diagnosis.  When  we  enter  the  field  of  the 
specialists,  such  as  the  oculist,  the  laryngologist,  the 
orthopedist,  et  cetera, — a  vast  technique  appears  in 
which  the  use  of  special  apparatus  is  one  element,  and 
special  skill  of  hand  and  mind  is  the  other.  The 
average  practitioner  and  the  average  patient  are 
largely  deprived  of  these  facilities.  Therefore,  opti- 
cians and  optometrists  flourish,  oculist's  services 
being  so  limited.  The  dealer  in  braces,  foot-plates, 
etc.,  does  a  thriving  business  at  a  high  rate  of  profit 
because  the  orthopedist  can  reach  but  few.  Above 
all,  vendors  of  patent  medicines  sell  thousands  of  con- 
coctions for  millions  of  dollars,  largely  because  even 
those  physicians  who  had  modern  training  in  diagnosis, 
have  not,  after  they  enter  practice,  the  facilities  for 
using  their  training  effectively  with  the  average  pa- 
tient, or  for  securing  for  their  patients  the  services  of 
specialists,  because  the  patients  cannot  afford  the 
specialists'  private  rates.  In  other  words,  the  prog- 
ress of  medical  science  calls  for  an  increasing  invest- 
ment of  capital  in  the  form  of  equipment,  and  of  time 
in  acquiring  special  training.  The  average  physician 
cannot  supply  the  needed  capital  nor  give  the  neces- 
sary time.  The  doctor  suffers  and  so  do  his  patients. 
What  is  the  remedy? 

Organization  versus  Individualism 

4.  The  remedy  is  twofold.     On  the  one  hand,  there 
must  be  specialization  in  various  branches  of  medi- 


350  DISPENSARIES 

cine,  so  that  the  need  for  special  skill  may  be  confined 
to  a  field  sufficiently  narrow  to  enable  the  average  man 
to  master  it.  Second,  there  must  be  co-operative  in- 
stead of  individual  provision  and  use  of  equipment. 
In  medicine  as  in  business,  organization  must  replace 
individualism. 

No  one  even  slightly  familiar  with  the  vast  existing 
mass  of  medical  knowledge  and  with  its  rapid  growth, 
can  believe  that  any  less  development  of  specializa- 
tion than  exists  today  in  the  practice  of  medicine  is 
possible  in  the  future.  No  fair-minded  person  can 
fail  to  admit  that  specialization  reveals  possibilities 
of  efficient  diagnosis,  treatment  and  prevention  of 
disease  which  were  previously  unknown.  It  must  be 
admitted  with  equal  frankness  that  with  specializa- 
tion we  face  the  risk  of  breaking  or  diminishing  the 
individual  interest  and  close  relationship  between 
patient  and  doctor  which  were  the  central  source  of 
power  in  the  traditional  family  physician  system. 
But  in  medicine,  as  in  industry,  specialization  re- 
quires organization  to  develop  maximum  efficiency. 
With  the  advance  of  medical  science,  and  the  rise  of 
specialties,  there  has  begun  to  develop  medical  organi- 
zation. We  see  this  most  concretely  incorporated  in 
the  hospitals.  Dispensaries,  and  public  health  depart- 
ments. The  Dispensary  was  originally  a  place  in 
which  an  individual  physician  might  look  at  and  give 
prescriptions  to  a  series  of  patients.  Today,  well- 
managed  Dispensaries  are  centers  for  co-operative 
medical  practice.  So  the  hospital  was  once,  not  a 
medical  organization,  but  merely  a  medical  hotel.     In- 


THE   MEDICAL  PROFESSION  351 

dividual  doctors  treated  their  patients,  each  for  him- 
self, with  no  central  medical  organization  and  no  more 
consultation  or  co-ordination  in  practice  than  if  the 
patient  had  been  cared  for  at  home.  Such  is  the  sit- 
uation in  many  private  hospitals  today.  The  modern 
hospital  is  not  a  medical  hotel;  the  modern  Dispen- 
sary is  not  a  medical  soup-kitchen.  Each  is,  first  and 
foremost,  a  medical  organization.  Co-operative  medi- 
cal practice  has  its  home  therein,  and  its  essentials,  as 
stated  in  an  early  chapter  of  this  volume,  are  two: — 
the  organization  of  equipment  and  the  organization 
of  skill. 

Specialist  Medical  Practice 

5.  Medical  organization  indeed  exists  to  a  certain 
extent  among  physicians  in  private  practice.  Many 
persons  now  and  then  employ  consultants  or  special- 
ists and  when  a  general  practitioner  refers  a  patient 
to  a  specialist  or  a  consultant,  he  follows  the  medical 
organization  developed  within  the  profession.  The 
opinions  of  the  consultant  or  specialist  are  given  to 
the  family  physician  or  general  practitioner  and  by 
him  interpreted  to  the  patient,  with  recommendations. 
Treatment,  as  well  as  advice,  may  be  furnished  by  one 
or  more  of  the  specialists.  The  relationship  between 
the  different  physicians,  and  their  interchange  of 
opinions  and  recommendations,  takes  place  in  per- 
sonal conversation,  by  correspondence,  or  over  the 
telephone.  The  patients,  if  very  ill,  may  be  visited 
at  home  by  one  or  more  of  the  co-operative  group  or, 
may  be  seen  in  a  hospital  by  them.    If  the  case  is 


352  DISPENSARIES 

ambulatory,  the  patient  may  go  from  one  physician's 
office  to  another.  This  is  what  we  may  call  specialist 
medical  practice.  It  is  utilized  by  all  social  classes  on 
occasion,  but  it  is  the  prevalent  and  typical  form 
among  the  well-to-do  and  the  wealthy.  The  method 
is  necessarily  expensive  and  elite.  It  is  time-consum- 
ing for  the  physicians,  for  (except  the  unusually  pop- 
ular men  who  are  over-run  by  patients)  the  doctor 
must  work  discontinuously.  It  requires  the  mainte- 
nance of  many  separate  offices,  with  inevitable  dupli- 
cation of  plant,  of  paid  assistants,  and  of  professional 
equipment. 

Cooperative  Medical  Practice 

6.  In  what  we  will  designate  co-operative  practice^ 
in  the  hospital  and  the  Dispensary,  we  have  simi- 
lar professional  relationships  between  the  physicians, 
but  we  have  these  physicians  brought  together  within 
a  single  building  or  a  group  of  connected  buildings. 
The  equipment  is  pooled  and  under  centralized  con- 
trol. The  same  control  applies  to  the  admission  of 
patients  and  to  the  finances,  thus  setting  the  physi- 
cians free  for  their  one  professional  duty — medical 
work  with  patients.  The  administrative  machinery 
for  dealing  with  records  and  for  interchange  of  in- 
formation, minimizes  time  and  expense.  Diagnostic 
and  therapeutic  facilities  can  be  provided  on  a  scale 
otherwise  unavailable,  except  to  a  few  doctors.  The 
opportunities  for  study  and  for  mutual  consultations, 
in  a  well-equipped  hospital  or  Dispensary,  are  superior 
to  what  they  can  be  even  in  the  most  expensive  type 


THE  MEDICAL  PROFESSION  363 

of   specialist   practice   through   separate   physicians' 
offices. 

The  general  public  and  a  number  of  physicians  do 
not  as  yet  understand  the  nature  and  advantage  of 
this  new  type  of  medical  work.  They  still  think  of  the 
hospital  as  a  medical  hotel,  and  lookfdown  upon  the 
Dispensary  as  a  medical  soup-kitchen!  The  con- 
ception of  the  hospital  and  the  Dispensary  as  institu- 
tions in  which  highly  efficient  medical  service  can  be 
rendered  because  of  the  organization  and  equipment 
which  are  possible  therein,  is  beginning  to  pervade  the 
profession  and  to  penetrate  among  the  general  public. 
But  the  general  practitioner  has  raised  an  indictment 
against  the  hospital  and  the  Dispensary.  He  has  de- 
clared that  they  are  ''taking  practice  away  from  him 
and  his  brethren  in  the  medical  profession,  without 
providing  remuneration  in  return.  Is  this  charge 
well-founded?     If  so,  how  shall  it  be  met? 

7.  The  rapid  growth  of  Dispensaries  in  recent  years 
has  doubtless  been  largely  due  to  the  increased  use  of 
specialists  by  those  of  small  means.  The  average  self- 
supporting  wage-earning  family  or  the  small  business 
man  calls  in  a  general  practitioner  at  times  of  serious 
or  discommoding  illness.  Consultation  can  rarely  be 
afforded  and  the  people  are  so  little  familiar  with  the 
trend  of  modern  medicine  that  if  a  physician  were  to 
suggest  a  consultation,  they  would  often  suspect  a  con- 
fession of  weakness  on  his  part,  and  be  inclined  to 
leave  him,  perhaps  for  a  less  conscientious  man.  The 
mass  of  the  people  can  rarely  pay  for  specialists  and 
cannot  afford  at  all  the  advice  of  a  group  of  specialists, 


354  DISPENSARIES 

such  as  the  well-to-do  secure.  An  analysis  of  the  at- 
tendance at  various  representative  Dispensaries  in 
New  York  City  and  Boston  shows  that  fifty  per  cent 
or  more  of  the  attendance  is  in  clinics  dealing  with  the 
specialties,  i.e.,  other  than  the  general  medical,  pedi- 
atric, and  surgical  clinics. ^^  Persons  whose  incomes 
place  them  at  or  below  the  poverty  line  secure  their 
general  medical  service  through  the  Dispensaries,  but 
many  families  who  ordinarily  employ  the  private 
physician  as  a  general  practitioner  now  secure  the 
special  services  which  they  need  through  the  Dispen- 
saries, coming  on  their  own  initiative  or,  less  fre- 
quently, at  the  suggestion  of  their  physicians. 

The  Dispensary  is  thus  providing  general  medical 
service  for  the  lower  economic  levels  of  the  population, 
and  specialists'  service  to  a  considerable  number  of 
individuals  from  somewhat  higher  economic  levels. 
So  long  as  the  Dispensary  was  not  only  regarded,  but 
actually  was,  a  soup-kitchen  for  the  destitute,  it  was 
properly  provided  for  by  volunteer  medical  service. 
The  destitute  constitute  a  small  part  of  any  popula- 
tion and  must  be  cared  for  by  medical  charity  in  one 
form  or  another ;  but  when  the  Dispensary  grew  from 
a  medical  soup-kitchen  into  a  form  of  medical  prac- 
tice, the  relationship  to  the  profession  was  radically 
altered  and  this  should  have  been  recognized  by  a 
change  in  the  financial  relationship  between  the  insti- 
tutions and  their  medical  staffs. 


THE   MEDICAL   PROFESSION  355 

Remuneration  of  Medical  Staffs 

The  lay  public  is  still  imbued  with  the  tradition  that 
'^  doctors  give  their  services  to  charitable  hospitals  and 
Dispensaries.''  Popular  understanding  of  the  changed 
relationship  of  these  institutions  is  necessary,  and  must 
be  brought  about  by  every  available  means;  for  only 
as  the  general  public  comprehends  the  potentialities 
for  human  service  which  lie  in  co-operative  medical 
practice  can  the  financial  support  for  its  extension  be 
secured,  and  the  medical  profession  be  adequately 
remunerated. 

8.  Why  has  the  change  not  been  more  widely  rec- 
ognized as  yet?  In  considerable  measure  because  the 
situation  has  been  obscured  through  the  enlarged 
use  of  the  Dispensary  by  teaching  institutions.  The 
teaching  Dispensary  often  does  furnish  its  medical 
staff  remuneration  of  a  real  nature,  even  without 
salary.  Opportunities  for  study,  for  the  acquirement 
of  prestige  through  research  and  publication,  are  a 
frequent  by-product  of  a  position  on  the  staff  of  an 
important  teaching  Dispensary.  Furthermore,  the 
teaching  of  medical  students  is  in  itself  an  important 
contribution  to  a  doctor's  prestige,  and  later,  when  the 
students  are  in  practice,  they  are  likely  to  supply  re- 
munerative consultations.  The  teaching  Dispen- 
saries have  been  the  centers  of  progress  in  Dispensary 
work.  They  have  led  the  way.  Other  Dispensaries 
have  followed  them,  and  have  continued  the  tradition 
of  unpaid  medical  service.  In  medical  schools  of  high 
standing  there  is  a  strong  tendency  to  transform  un- 


356  DISPENSARIES 

paid  into  paid  medical  staffs  for  the  purpose  of  secur- 
ing efficiency  in  medical  research  and  in  teaching. 
Medical  teaching  today,  in  all  the  clinical  branches, 
means  medical  practice;  that  is,  the  treatment  of 
cases  of  disease.  If  the  best  equipped  Dispensaries, 
under  the  auspices  of  medical  schools  of  high  stand- 
ing, are  finding  that  paid  medical  staffs  are  a  require- 
ment of  efficiency,  certainly  Dispensaries  not  fortunate 
enough  to  have  such  teaching  connections  should  find 
this  true  also.  The  continuance  of  unpaid  medical 
staffs  in  Dispensary  service  is  incompatible  with  either 
the  best  efficiency  in  co-operative  practice  or  with 
justice  to  the  medical  profession. 

How  shall  the  consequent  financial  burden  be  met 
by  Dispensaries?  As  shown  in  the  chapter  on  Fi- 
nance, the  payment  of  salaries  to  medical  staffs 
means  doubling  the  expense  as  compared  with  a  Dis- 
pensary that  has  volunteer  medical  service.  The  Pay 
Clinic,  charging  fees  to  cover  the  full  cost,  including 
medical  salaries,  may  be  a  partial  answer  to  this  ques- 
tion, but  a  much  broader  solution  to  the  financial 
problem  must  be  found.  This  is  discussed  in  the  next 
chapter. 

Democratizing  Cooperative  Medical  Practice 

9.  Looking  further  at  the  Dispensary,  from  the 
standpoint  of  medical  organization,  we  may  perceive 
another  serious  deficiency  in  the  present  relationship 
between  Dispensaries  and  the  medical  profession. 
Only  a  small  proportion  of  physicians  share  in  the 
facilities  offered  by  Dispensaries  for  diagnosis  and 


THE  MEDICAL  PROFESSION  357 

treatment  of  patients,  and  for  medical  advancement. 
In  Boston,  a  city  where  medical  institutions  are  im- 
usually  well  developed,  an  examination  of  the  reports 
of  the  institutions  showed  that  in  1915,  slightly  less 
than  twenty-five  per  cent  of  the  2,800  physicians  of 
Greater  Boston  were  attached  to  the  staffs  of  hospitals 
and  Dispensaries.  Seventy-seven  per  cent  appeared 
to  have  no  such  connection. 

In  New  York,  where  Dispensaries  have  probably 
developed  further  than  anywhere  else  in  the  United 
States,  data  published  in  the  Journal  of  the  American 
Medical  Association,  June  9,  1917,  showed  that  thirty- 
seven  and  a  half  per  cent  of  the  physicians  in  New 
York  City  gave  some  work  to  its  106  Dispensaries.  A 
certain  number  of  additional  men  were  members  of 
hospital  staffs.  It  is  safe  to  say  that  considerably 
less  than  fifty  per  cent  of  the  physicians  of  New  York 
City  are  on  the  staffs  of  its  medical  institutions. 

In  most  communities,  the  proportion  of  physicians 
who  have  access  to  modern  institutional  facilities  for 
diagnosis  and  treatment  would  be  much  smaller. 

The  Dispensary,  therefore,  needs  not  only  to  be 
made  more  efficient  by  improvements  in  the  internal 
organization  and  by  adequate  financial  support,  but 
also  to  be  democratized  in  its  relationship  to  the  medi- 
cal and  the  lay  community.  The  advantages  of  Dis- 
pensaries need  to  reach  all  the  people  who  need  them 
and  all  the  doctors  who  know  how  to  use  them. 


358  DISPENSARIES 

Trend  Toward  more  Dispensary  Work 

10.  In  considering  the  relationship  of  the  general 
practitioner  to  the  Dispensary,  it  is  well  to  bear  in 
mind  that  an  increasing  proportion  of  medical  work 
has  to  deal  with  ambulatory  rather  than  bed  cases. 
Too  much  of  the  doctor's  service  in  ordinary  general 
practice  among  the  masses  of  the  population  is  bedside 
work  for  the  acutely  sick.  The  pressure  of  the  move- 
ment for  public  health  education  is  largely  in  the 
direction  of  encouraging  people  to  go  to  the  doctor  in 
early  stages  of  disease,  when  symptoms  just  begin  to 
be  prominent.  In  proportion  as  this  develops  the 
doctor  will  see  ambulatory  rather  than  bed  cases. 
Moreover,  the  work  of  many  specialists  is  chiefly  with 
ambulatory  patients.  This  is  true  to  a  large  extent 
of  the  oculist,  the  laryngologist,  the  orthopedist,  the 
dermatologist,  the  neurologist,  and  the  dentist. 

We  may  also  mention  the  development  of  industrial 
medicine  as  an  additional  force  behind  the  public 
health  propaganda,  tending  to  bring  patients  to  the 
doctor  in  the  ambulatory  and  therefore  early  stages  of 
disease. 

The  increase  in  the  relative  importance  of  ambula- 
tory work  is  of  the  greatest  significance  for  the  future 
of  the  Dispensary,  and  in  fact  for  the  organization  of 
medical  practice  itself.  Work  with  ambulatory  pa- 
tients is  capable  of  a  high  degree  of  organization  in 
such  a  manner  as  to  promote  economy  of  time  on  the 
part  of  both  patients  and  doctors,  and  also  economy 
in  the  provision  and  administration  of  professional 
equipment.     The  same  tendencies  tend  to  make  it 


THE  MEDICAL  PROFESSION  359 

more  advantageous,  financially  and  medically,  for 
work  to  be  done  at  the  doctor's  office  or  in  the  medical 
institution  (Dispensary)  rather  than  in  the  patient's 
home.  More  and  more  does  the  doctor  need  to  work 
where  his  professional  equipment  is.  Medical  forces, 
conjoined  with  public  health  and  industrial  move- 
ments, are  thus  combining  to  create  favorable  condi- 
tions for  increase  of  Dispensary  work  in  the  future. 

Three  Problems 

11.  The  analysis  of  this  chapter  leaves  us  with 
three  problems,  to  which  Chapters  XXI,  XXII  and 
XXIII  are  respectively  devoted: — 

1.  How  shall  Dispensaries  be  so  organized  internally  as 
to  be  medically  efficient  in  diagnosis  and  treatment,  and 
comfortable  and  dignified  for  the  patient? 

2.  How  shall  there  be  secured  proper  financial  support 
for  the  maintenance  of  these  Dispensaries,  including  ade- 
quate remuneration  for  the  medical  staff? 

3.  How  shall  Dispensaries  be  fitted  into  the  medical  and 
social  organization  of  their  communities  so  that  their  ad- 
vantages shall  be  available  'Ho  all  the  patients  who  need 
them  and  all  the  doctors  who  know  how  to  use  them"? 


24 


360  DISPENSARIES 


CHAPTER  XXI 
THE    EFFICIENT    DISPENSARY    OF    THE    FUTURE 

In  the  best  Dispensaries  today,  a  high  degree  of 
proficiency  in  different  branches  of  medicine  and 
surgery  may  be  found.  PecuHar  excellence  in  one 
branch  of  work  will  be  developed  in  one  institution, 
while  another  of  equally  high  general  standing  will 
have  laid  especial  stress  upon  another  branch.  The 
important  part  which  the  interests  of  medical  teach- 
ing have  played  in  developing  Dispensaries  has  led 
to  occasional  over-emphasis  upon  diagnosis  as  com- 
pared with  the  problems  of  treatment.  But  in  recent 
years  this  emphasis  has  shifted,  and  something  at 
least  approaching  a  proper  balance  has  now  been 
established  in  the  minds  of  the  leaders  in  Dispensary 
service. 

The  chief  deficiencies  found  even  in  the  best  Dis- 
pensaries at  the  present  time  are  these: — 

1.  A  medical  organization  not  sufficiently  centralized, 
so  that  the  patient  is,  as  it  were,  divided  up  between  clinics 
without  adequate  central  medical  control  and  interpreta- 
tion. 

2.  Too  much  hurry,  too  little  comfort,  too  little  dignity 
for  the  patient. 

3.  Lack  of  adaptation  to  the  needs  of  a  clientele  of  wage- 
earners. 


THE  EFFICIENT  DISPENSARY  361 

Centralized  Medical  Control 

1.  The  first  of  these  deficiencies  is  due  in  large 
part  to  carrying  over  into  the  work  of  the  Dispensary 
the  habit  of  medical  organization  established  in  private 
specialist  practice.  It  is  fair  to  say  that  in  the  best 
Dispensaries  the  medical  organization  is  substan- 
tially better  than  in  private  speciaHst  practice.  In 
only  a  few  experimental  instances  as  yet,  however, 
have  Dispensaries  attained  the  ideal  of  securing  for 
the  patients  an  initial  general  medical  examination, 
with  continuous  further  control  and  interpretation 
by  the  general  medical  authority  of  all  other  medical 
and  surgical  specialist  data.  Each  patient  needs  to 
have  (with  certain  exceptions  hereafter  noted)  a  single 
physician,  who  will  usually  be  the  general  medical 
man  (or  in  the  case  of  children  the  pediatrician). 
This  physician  should  be  the  one  whom  he  will  see  to 
secure  the  interpretation  and  advice  which  may  come 
either  from  this  physician's  examination  or  from  the 
specialists  to  whom  the  patient  is  referred.  The  same 
patient  should  normally  see  the  same  physician  at 
each  visit. 

Exceptions  may  of  course  be  made  in  this  central- 
ized system  of  medical  control  and  interpretation  in 
the  case  of  some  highly  specialized  or  temporary 
disorders;  minor  surgical  injuries  are  an  example. 
Comparatively  few  laymen  yet  appreciate  the  value 
of  regular  medical  examination,  and  on  going  to  a 
medical  institution  would  be  surprised,  possibly 
antagonistic,  if  they  were  asked  to  receive  a  general 
medical  examination,  whereas  they  went  to  see  the 


362  DISPENSARIES 

''eye  doctor"  or  the  dentist.  The  carrying  out  of 
the  principle  of  central  medical  control  for  a  patient 
must  therefore  be  tempered  with  common  sense,  and 
the  advancement  of  the  principle  in  practice  will 
depend  upon  the  education  of  the  general  public,  as 
well  as  upon  better  organization  within  the  medical 
profession  and  the  medical  institutions  themselves. 

Dignity  and  Comfort  for  Patients 

2.  The  second  great  deficiency — the  overcrowding, 
hurry,  lack  of  comfort  and  dignity  for  the  patient — 
will  largely  take  care  of  itself  as  Dispensaries  are 
democratized  and  medical  staffs  are  properly  remun- 
erated. Patients  who  are  merely  ' '  ob j  ects  of  charity, ' ' 
or  '^clinical  material,"  will  be  treated  as  such,  hu- 
manely but  without  any  extreme  regard  for  personal 
privacy  or  dignity.  This  is  true  in  all  but  exceptional 
cases.  If  Dispensaries  should  be  supported  either  by 
fees  from  patients  themselves  or  by  insurance  funds 
to  which  patients  contribute  at  least  part,  or  by  public 
funds,  which  the  patients  as  citizens  feel  they  have  a 
share  in  providing,  there  would  naturally  be  produced 
a  substantial  difference  in  the  point  of  view  from 
which  the  patient  is  regarded.  Adequate  compensa- 
tion for  the  medical  staff  will  relieve  the  average 
physician  from  the  necessity  of  hurrying  in  order  to 
get  to  his  remunerative  work  in  private  practice.  His 
strong  professional  instinct  for  treating  people  well, 
as  human  beings  as  well  as  patients,  will  assert  itself 
with  a  double  force  in  the  clinic  when  the  present 
unnatural  pressure  upon  the  unpaid  Dispensary  phy- 


THE  EFFICIENT  DISPENSARY  363 

sician  is  relieved.  We  may  therefore  look  to  better 
attention  to  the  individual  patient,  to  more  privacy, 
less  hurry  and  more  dignity,  largely  as  an  indirect 
result  of  other  changes.  This  indirect  result,  however, 
is  of  vital  importance,  and  the  forces  which  may  bring 
it  about  indirectly  must  be  assisted  by  direct  educa- 
tional effort. 

A  system  of  volunteer  medical  service  obviously 
prevents  any  physician  from  giving  more  than  a  small 
fraction  of  a  day  to  a  dispensary  clinic.  With  a 
salaried  service,  clinics  could  be  open  for  longer  pe- 
riods, sometimes  continuously,  and  the  concentration 
of  many  patients  within  a  short  period  of  time  could 
be  greatly  diminished.  The  expensive  equipment  of 
a  modern  medical  institution  ought  to  be  utilized  as 
continuously  as  possible 

Adapting  Clinics  to  Wage-Earners 

3.  Mpst  Dispensaries  serve  wage-earners  and  their 
families,  yet  most  maintain  clinics  only  during  work- 
ing hours.  A  very  serious  loss  in  time  and  wages 
falls  upon  employed  men  and  women  through  attend- 
ance at  a  clinic.  Investigation  made  at  one  clinic 
indicated  an  average  wage  loss  of  seventy-five  cents 
and  as  this  included  many  women  patients,  a  figure 
covering  men  alone  would  be  much  higher.  More- 
over, in  the  case  of  diseases  requiring  frequent  visits 
to  the  doctor,  repeated  absence  from  work  may  cause 
not  only  loss  of  wages  but  the  threatened  or  actual 
loss  of  a  job.  Thus  the  evening  pay  clinics  described 
in  Chapter  XIX  have  an  economic  foundation. 


364  DISPENSARIES 

Obviously  so  long  as  medical  staffs  are  unpaid, 
clinics  must  be  ''run''  at  hours  most  convenient  to 
them.  But  as  we  progress  toward  regarding  Dis- 
pensaries as  agencies  of  health  service  rather  than  as 
charities,  the  economy  of  holding  clinics  after  working 
hours  will  be  more  and  more  apparent.  Whether  as 
free  clinics  or  pay  clinics.  Dispensaries  which  conduct 
some  or  all  of  their  work  for  adults  during  the  late 
afternoon  or  evening  hours  are  a  necessity  for  the 
future. 

In  the  preceding  chapters  of  this  book,  we  have  gone 
into  the  various  technical  questions  of  organization 
of  medical  staff,  the  equipment  and  management  of 
clinics,  etc.  It  is  not  necessary  to  rehearse  these,  but 
it  will  be  useful  to  summarize  briefly  the  general 
requirements  for  the  efficient  Dispensary  of  the  future : 

What  an  Efficient  Dispensary  Needs 

1.  A  medical  staff  properly  remunerated  for  its  services. 

2.  A  medical  organization  facilitating  co-operative  diag- 
nosis and  treatment,  and  also  providing  central  medical 
control  in  each  patient's  case,  data  to  be  interpreted  for 
and  to  the  patient  by  a  single  physician  with  whom  the 
patient  early  establishes  certain  personal  relations. 

3.  Central  administrative  control  of  all  branches  of  the 
Dispensary  service,  carried  out  by  a  strong  executive  officer, 
under  a  board  or  committees  in  which  the  medical  interests 
of  the  staff  and  the  interests  of  the  lay  community  are  both 
represented. 

4.  Administrative  organization  such  as  will  secure  reason- 
able comfort,  privacy  and  dignity  for  the  individual  patient. 

5.  Buildings  and  equipment  of  proper  standards. 


THE  EFFICIENT   DISPENSARY  365 

In  addition  to  these  fundamental  requisites,  the 
following  more  technical  requirements  may  be  men- 
tioned, recapitulating  previous  chapters. 

6.  Good  nursing;  adequate  clerical  help;  a  staff  (social 
service)  for  stud3'ing  the  social  problems  of  patients  and 
assisting  the  physicians  in  the  education  of  patients  and  the 
control  of  their  environment  necessary  to  secure  the  best 
medical  results. 

7.  The  linking  up  of  the  dispensary  service,  through  the 
medium  of  this  social  service  staff,  with  educational,  chari- 
table, public  health,  industrial  and  other  community 
resources. 

8.  A  good  admission  system. 

9.  A  good  central  record  system. 

10.  A  follow-up  system  for  the  supervision  and  control 
of  attendance. 

11.  Periodical  efficiency  tests. 

12.  Annual  accounting  and  reports  to  the  pubhc  of  work 
done,  expenses  incurred,  and  results  secured. 

Future  Types  of  Dispensaries 

Following  the  consideration  of  the  '^efficient  Dis- 
pensary" in  this  general  way,  we  may  examine  the 
various  existing  types  of  Dispensaries  with  reference 
to  their  probable  future.  No  one  can  doubt  the  large 
future  growth  of  the  public  health  Dispensary,  both 
in  its  present  types,  dealing  with  tuberculosis,  babies, 
etc.,  and  in  types  adapted  to  other  diseases  and  medi- 
cal problems.  With  little  doubt  the  co-ordination  of 
different  branches  of  public  health  work  will  cause  the 
public  health  Dispensaries  of  the  future  to  take  chiefly 
the  form  of  Health  Centers,  each  serving  a  district  of 


366  DISPENSARIES 

specified  area  and  uniting  in  one  building,  with  more 
or  less  centralized  administrative  organization,  the 
various  branches  of  clinical  and  prophylactic  health 
work  which  may  be  carried  on  for  that  district.  The 
chief  present  question  is  the  extent  to  which  the 
medical,  nursing  and  social  services,  in  the  various 
specialties,  can  be  unified  administratively. 

Our  analysis  of  the  trend  of  medical  service  has 
emphasized  the  importance  of  adequate  professional 
equipment,  and  suggests  the  advantage  of  the  out- 
patient department  of  a  hospital,  as  against  the  out- 
patient institution  separate  from  a  hospital.  The 
Health  Centre  and  the  small  District  Dispensary, 
confining  attention  to  minor  diseases  and  to  certain 
specialized  lines  of  clinical  work,  may  well  have  a 
permanent  future.  But  where  difficult  diagnostic 
work  is  required,  or  even  where  a  large  group  of  gen- 
eral diseases  is  to  be  properly  diagnosed  and  treated, 
the  advantages  of  making  a  Dispensary  part  of  a 
hospital  organization  are  so  great  as  to  leave  little 
future  for  any  large  out-patient  institution  separate 
from  a  hospital.  Of  course  an  institution  which  is 
under  the  control  of  a  separate  corporation,  but  which 
is  organized  as  part  of  a  medical  school,  and  which  is 
in  practical  administrative  unification  with  a  hospital, 
complies  with  the  requirement  above  laid  down. 
Actual  and  not  merely  formal  combination  between 
the  out-patient  institution  and  the  hospital  is  the 
requisite.  It  is  not  necessary  that  the  out-pa- 
tient institution  shall  be  immediately  contiguous  to 
the  hospital  in  order  to  secure  its  advantages.     The 


THE   EFFICIENT   DISPENSARY  367 

important  point  is  that  there  shall  be  unification  of 
the  medical  organization  between  the  out-patient 
institution  and  the  hospital,  and  while  propinquity 
is  an  advantage  it  is  not  an  essential.  In  many  com- 
munities it  will  be  desirable  to  have  only  a  single 
hospital,  or  a  very  few  hospitals,  but  several  well- 
equipped  Dispensaries.  The  needs  of  serving  a 
certain  area  by  a  local  well-equipped  Dispensary  may 
thus  require  that  a  single  hospital  have  more  than 
one  branch  of  its  out-patient  department. 

We  may  also  anticipate  that  large  specialized 
Dispensaries  will  not  be  developed  further  to  any 
great  extent.  We  have  noticed  in  the  review  of  the 
growth  of  Dispensaries,  in  the  early  chapters,  that 
the  eye  and  ear  institutions,  the  neurological,  ortho- 
pedic, nose  and  throat,  and  gynaecological  Dispen- 
saries, confining  their  attentions  to  a  narrow  specialty, 
have  not  grown  to  any  large  extent,  whereas  the  gen- 
eral Dispensaries  have  increased  with  great  rapidity. 
This  is  as  it  should  be. 

The  industrial  Dispensary  undoubtedly  has  a  large 
future.  Its  chief  present  limitation  is  its  exclusive 
control  by  the  employer.  There  is  a  growing  opposi- 
tion among  working  people  to  periodical  medical 
examinations  or  other  medical  work,  which  employees 
fear  may  be  used  by  an  employer  to  discriminate 
among  workmen  for  other  reasons  than  industrial 
efficiency.  However  little  or  much  this  fear  may  be 
grounded,  the  fact  that  it  exists  remains,  and  it 
appears  to  be  increasing  rather  than  diminishing. 
The  industrial  Dispensary,  and  the  related  forms  of 


368  DISPENSARIES 

medical  work  which  are  growing  up  along  with  it, 
such  as  periodic  examinations  of  working  forces,  may 
encounter  serious  social  obstacles  unless  its  control 
and  supervision  can  be  democratized*  It  is  possible 
that  a  health  insurance  system,  such  as  exists  in 
Germany  or  England,  might  take  the  industrial 
Dispensary  under  the  control  of  its  local  fund.  To 
these  funds  the  worker  and  the  employer  contribute 
financially  under  the  foreign  systems,  and  share 
jointly  in  the  management. 

This  is  by  no  means  the  only  method  by  which 
co-operative  support  and  control  of  industrial  Dis- 
pensaries could  be  secured.  Many  existing  voluntary 
insurance  funds  in  industrial  establishments  in  the 
United  States  are  supported  partly  by  the  employer 
and  partly  by  the  workers.  Joint  control  should 
follow  joint  support;  and  in  the  long  run  there  would 
be  a  substantial  benefit  to  the  employer  from  greater 
co-operation,  on  the  part  of  the  workers,  in  the  health 
programs  which  the  physicians  of  the  industrial  medi- 
cal staff  lay  down. 

Public  Regulation  of  Dispensaries 

What  of  the  commercial  Dispensary?  Will  there 
be  more  than  one  Mayo  Clinic?  Will  every  large  city 
have  such  clinics  in  the  future?  Very  possibly  they 
will  develop,  as  the  advantages  of  such  co-operative 
medical  practice,  for  all  social  classes  become  more 
generally  perceived.  The  commercial  Dispensary  of 
the  cheap  type,  such  as  appears  to  a  certain  extent  in 
some  cities,  is  not  likely  to  penetrate  far  beyond  the 


THE  EFFICIENT  DISPENSARY  369 

fringe  of  medical  service.  It  can  with  difficulty 
compete  against  public  service  institutions,  supported 
by  state  funds  or  endowments.  Public  regulation 
of  all  forms  of  organized  medical  service,  including 
Dispensaries,  will,  however,  be  necessary,  as  has 
already  been  found  to  be  the  case  in  some  states  and 
cities.  Only  thus  can  ^' quack"  enterprises  be  effect- 
ively crushed  out;  only  thus  can  undesirable  enter- 
prises for  commercial  exploitation  of  the  sick,  through 
Dispensaries  or  otherwise,  be  kept  under  control. 
The  health  department  of  the  state,  or  possibly  in 
some  cases  of  a  city,  should  have  the  power  to  license 
all  Dispensaries,  should  be  required  to  make  at  least 
an  annual  inspection,  and  should  be  empowered  to 
prescribe  the  general  standards  of  the  building,  equip- 
ment, sanitation  and  operation  of  the  institution. 
Regulation  in  New  York  State  has  been  attempted 
through  the  State  Board  of  Charities,  but  this  plan 
has  serious  disadvantages.  It  does  not  cover  the 
commercial  Dispensaries,  and  it  places  the  Dispensary 
in  the  position  of  being  regulated  if  it  is  a  charity,  but 
of  being  without  public  control  if  it  is  a  commercial 
enterprise.  A  State  Board  of  Charity  may  well  be 
given  sufficient  power  to  see  that  where  charitable 
funds  exist  in  Dispensaries,  as  in  any  other  institu- 
tions, these  funds  shall  be  properly  managed.  But  the 
general  power  to  supervise  all  types  of  Dispensaries, 
as  medical  institutions,  should  be  vested  in  a  public 
health  authority.  A  law  just  passed  (March,  1918) 
in   Massachusetts    requires    all   Dispensaries   to   be 


370  DISPENSARIES 

licensed  by  the  State  Department  of  Health.     The 
operation  of  this  act  should  be  watched  closely.* 

The  Teaching  Dispensary  of  the  Future 
The  advance  of  Dispensaries  along  the  lines  here 
indicated  will  be  in  no  way  incompatible  with  their 
utilization  in  education.  In  a  properly  conducted 
clinic,  the  teaching  of  medical  students  proves  of 
benefit  to  the  patients,  not  a  detriment.  The  dis- 
advantages which  are  now  sometimes  apparent  in 
teaching  clinics  are  due  to  the  same  causes  which  at 
present  limit  the  efficiency  of  all  clinics,  these  being 
chiefly  the  lack  of  a  right  point  of  view  toward  the 
patient  and  of  adequate  organization  and  remunera- 
tion of  the  medical  staff.  The  best  medical  teaching 
will  conform  in  spirit  and  in  practice  with  the  best 
organized  Dispensaries  of  the  future.  The  aim  must 
be  to  train  doctors  for  their  beneficent  public  function 
of  healing  and  of  preventing  disease.  The  out- 
patient clinic  must  be  not  only  for  observation  of 
symptoms  and  for  experience  in  diagnosis,  but  must 
be  a  school  in  the  treatment  of  human  beings.  To 
teach  people  what  they  need  and  how  to  do  what  they 
should  for  the  benefit  of  their  own  health,  is  more  and 
more  part  of  the  doctor's  task  in  private  practice. 
To  understand  people  and  to  know  how  to  deal  with 
them:  these  the  doctor  must  learn.  The  out-patient 
clinic  furnishes  admirable  opportunity  for  conjoint 
training  in  the  human  and  the  medical  factors  together. 
The  teaching  Dispensary  of  the  future  will  be  organ- 
ized so  as  to  develop  both  these  values,  and  in  thus 

*  The  text  of  this  law  is  printed  in  the  Appendix,  p.  427. 


THE  EFFICIENT   DISPENSARY  371 

* 

organizing  it  will  maintain  the  right  point  of  view 

toward  the  patient  and  the  right  conditions  of  general 
efficiency. 

Nor  does  the  program  for  the  future  Dispensary 
run  counter  to  the  spirit  of  charity  which  is  the  tradi- 
tional foundation  of  the  whole  Dispensary  movement, 
and  which  is  the  animating  force  behind  a  large  part  of 
its  present  manifestations.  We  have  already  traced 
a  broadened  conception  in  charity.  We  see  an  ad- 
vanced development  of  this  in  educational  institu- 
tions. Many  of  these  were  originally  founded  as 
charities,  for  the  ^^poor."  But  the  moving  and  char- 
acteristic spirit  in  the  college,  the  endowed  technical 
school,  even  the  southern  school  supported  out  of 
contributions  from  the  North,  is  a  spirit  of  public 
service  so  dominant  and  pervasive  that  a  student 
without  means  can  pay  a  fee  covering  far  less  than  the 
cost  of  his  education,  or  can  accept  a  scholarship, 
without  sense  of  dependence.  The  animating  spirit 
is  charity  in  that  large  sense  in  which  Saint  Paul 
used  the  term.  Medical  institutions  are  likely  to 
run  a  parallel  course.  We  are  beginning  to  regard 
medical  service,  for  the  preservation  and  restoration 
of  health,  as  a  public  necessity  as  well  as  an  individual 
need.  For  the  same  reasons  we  are  coming  to  look 
upon  the  medical  institution,  the  hospital  or  the 
Dispensary,  as  a  center  of  public  service,  a  charity  in 
the  meaning  of  a  service  but  not  in  the  meaning  of  a 
dole.  The  spirit  of  public  service,  which  is  the  goal 
if  not  the  apotheosis  of  charity,  will  animate  and 
control  the  medical  institution  of  the  future. 


372  DISPENSARIES 


CHAPTER  XXII 
FINANCING  BETTER  MEDICAL   SERVICE 

Is  the  financial  situation  of  the  medical  profession 
satisfactory?  There  are  no  general  data  as  to  the 
incomes  derived  from  individualistic  practice  by  the 
mass  of  doctors.  Some  men  achieve  large  incomes,  no 
doubt,  but  the  indications  are  that  the  average  is  not 
high.  It  is  certain  that  a  young  physician  without 
private  means  has  a  long  road  to  travel  before  he  can 
attain  an  assured  financial  position.  This  is  particu- 
larly true  if  he  wishes  to  keep  up  his  scientific  work 
begun  in  the  medical  school  and  during  his  hospital 
interneship;  for  while  he  is  likely  to  have  time  on  his 
hands  during  the  early  years  of  practice,  he  may  lack 
opportunity,  unless  he  possess  very  unusual  ability. 

Would  a  larger  and  more  general  participation  in  the 
work  of  medical  institutions,  and  in  co-operative 
medical  practice,  improve  the  financial  outlook  and 
status  of  the  rank  and  file  of  the  medical  profession? 
The  answer  is,  ^^Yes. '^  In  fact,  there  is  no  other 
general  method  by  which  such  improvement  can  be 
brought  about  simultaneously  with  an  enlargement 
of  service  to  the  public.  A  higher  average  income,  a 
more  stable  income,  a  larger  professional  opportunity 
for  the  average  physician  who  has  had  a  good  training 
to  start  with:  these  desiderata  can  only  arise  out  of 
more  comprehensive  organization  of  medical  service 


FINANCING   SERVICE  373 

than  exists  today.  And  such  organization  means 
essentially  more  work  done  in  medical  institutions; 
more  co-operative  practice.  By  reason  of  the  in- 
creasing demand  for  technical  equipment,  and  for  a 
longer  period  of  professional  training  for  the  physician, 
medical  service  is  becoming  inevitably  more  expensive 
under  conditions  of  private  competitive  practice. 
The  only  way  to  lower  its  cost  under  these  conditions 
is  to  cheapen  it  in  quality.  But  if  the  conditions  are 
altered  so  that  there  is  co-operative  provision  and  use 
of  equipment,  and  co-operative  organization  of  skill, 
the  quality  of  service  can  be  maintained,  and  in  fact 
the  average  quality  improved;  while  the  economies 
of  organization  would  permit  of  a  larger  average  re- 
muneration for  the  medical  man. 

The  desire  of  doctors  to  have  better  conditions  for 
their  profession  and  the  desire  of  the  general  public 
for  better  medical  service,  are  wholly  compatible  and 
tend  in  the  same  direction.  From  the  standpoint  of 
the  public,  the  study  of  the  economic  factors  underly- 
ing present-day  medicine  requires  an  analysis  of  the 
cost  of  medical  service  and  the  modes  in  which  this  is 
and  might  be  borne  by  the  community. 

Family  Budgets 

We  have  seen  in  a  previous  chapter  an  illustrative 
list  of  the  cost  of  treating  a  number  of  common  diseases, 
the  expense  ranging  from  a  few  dollars  to  hundreds  of 
dollars,  without  considering  major  surgical  operations 
or  nursing  service.  Previous  to  the  War,  when  the  cost 
of  living  was  much  lower  than  it  is  today,  careful  studies 


374  DISPENSARIES 

of  family  budgets  in  several  cities  ^^  demonstrated  that 
a  typical  family  of  five  persons  required  at  least  $850.00 
to  $900.00  income  in  a  year  to  maintain  mere  physical 
efficiency.  After  the  expenses  of  food,  shelter,  cloth- 
ing, fuel  and  light,  and  other  necessaries  had  been 
allowed  for,  the  amount  available  in  such  a  budget  for 
the  care  of  health  was  estimated  at  from  $18.00  to 
$25.00  a  year,  this  including  medical,  dental,  and 
nursing  service  and  also  medicine.  This  is  obviously 
insufficient  for  providing  medical  care  in  a  single  case 
of  serious  or  prolonged  illness,  even  if  this  illness  is 
not  of  the  wage-earner  himself,  so  that  the  income  of 
the  family  remains  unaffected.  When  the  wage- 
earner,  or  one  of  the  wage-earners,  in  such  a  family  is 
stricken,  income  wholly  or  partly  stops. 

Such  budget  studies  have  been  chiefly  concerned  in 
pointing  out  minimum  standards.  An  income  of 
$1,000.00  or  $1,200.00  a  year  for  a  similar  family  would 
provide,  not  a  surplus,  but  merely  a  slightly  better 
standard  of  living,  with  some  opportunity  for  educa- 
tional advantages  such  as  every  American  believes 
should  be  part  of  the  heritage  of  all  citizens.  Even 
before  the  War,  an  income  of  $1,000.00  could  hardly 
include  provision  for  a  serious  illness  of  any  member 
of  the  family,  much  less  in  the  chief  wage-earner.  The 
rise  in  cost  of  living  since  the  War  renders  all  the  pre- 
ceding estimates  much  below  the  present  truth. 

These  budget  studies  lead  us  to  two  important  con- 
clusions : 

1.  Families  with  incomes  of  from  $900.00  to  $1,200.00, 
while  generally  above  the  poverty  line,  cannot  on  the  average 


FINANCING  SERVICE  375 

provide  sufficient  margin  to  meet  the  cost  of  serious  or 
prolonged  illness,  or  especially  expensive  services,  even  when 
these  do  not  affect  the  chief  wage-earner. 

2.  In  such  families  there  usually  is,  however,  a  small 
margin,  enough  to  meet  all  or  a  large  part  of  the  cost  of 
needed  medical  care,  if  the  burden  of  occasional  illness 
could  be  distributed  by  either  taxation  or  insurance. 

We  may  observe  the  parallel  between  medical  serv- 
ice and  education.  Both  are  practically  universal 
needs.  Experience  has  proven  that  the  cost  of  provid- 
ing education  for  all  children  cannot,  or  will  not  be 
borne,  if  left  to  the  initiative  of  individual  families; 
and  that  the  education,  if  provided  in  this  way,  would 
be  neither  universal  nor  effective. 

Distributing  the  Burden  of  Illness 

Medical  service,  like  education,  is  needed  by  only 
a  small  part  of  the  population  at  one  time.  If  all  pay 
a  little  each  year,  a  fund  can  be  created  sufficient  to 
meet  the  expense  of  caring  for  the  relatively  small 
proportion  who  are  sick  during  any  one  period.  Each 
individual  who  is  capable  of  self-support  may  be 
expected,  in  the  long  run,  to  pay  his  fair  average  share. 

This  distribution  of  the  cost  of  medical  service  (and 
the  cost  of  meeting  the  living  expenses  of  the  family 
during  the  illness  of  the  wage-earner)  now  falls  entirely 
upon  the  individual  family  itself.  The  public  already 
recognizes  a  certain  responsibility  in  some  cases. 
When  a  family  is  destitute,  medical  service  is  provided 
as  a  charity  in  hospitals  and  Dispensaries  or  through 
the  generous  aid  of  individual  physicians.     But  so 

25 


376  DISPENSARIES 

long  as  the  burden  of  illness  falls  upon  the  sick  person, 
or  the  sick  person's  family,  at  the  time  of  illness  when 
the  ability  to  bear  the  burden  is  least,  we  cannot  ex- 
pect that  the  cost  of  efficient  medical  service  can  be 
met  generally  by  the  individual  alone. 

The  distribution  of  the  economic  burden  of  illness 
is  now  in  fact  proceeding,  though  slowly.  This  prog- 
ress is  taking  place  partly  through  the  extension  of 
health  activities  by  the  state  and  partly  through  the 
development  of  social  insurance.  There  is  continued 
increase  in  public  appropriations  for  health  work. 
This  appears  in  hospitals  and  Dispensaries  supported 
by  city  or  state  funds,  in  the  enlarging  scope  of  public 
health  departments  and  in  more  medical  service  in 
educational,  charitable  and  penal  institutions.  It  is 
noticeable  that  public  health  appropriations  tend  to 
be  for  preventive  work  rather  than  curative ;  yet  both 
are  extending  under  public  auspices. 

There  is  also  a  growing  trend  toward  Health  Insur- 
ance. Voluntary  agencies  such  as  fraternal  orders, 
sick  benefit  societies,  trade  unions,  and  industrial 
establishments  themselves,  are  giving  more  and  more 
attention  to  providing  cash  benefits  for  the  support  of 
the  worker  and  his  family  during  sickness,  and  also, 
in  some  cases,  to  the  provision  of  medical  care.  There 
is,  moreover,  appearing  a  demand  for  a  general  system 
of  Health  Insurance,  under  state  supervision  or  control, 
reaching  a  large  proportion  of  the  wage-earners  and 
others  of  limited  means.  Such  systems  are  in  opera- 
tion in  most  countries  abroad.  Nine  states  are  at 
present  studying  this  question  through  official  com- 


FINANCING  SERVICE  377 

missions,  and  a  number  of  voluntary  bodies  are  at 
work.  There  is  little  doubt  that  some  wider  utiliza- 
tion of  the  principle  of  insurance  for  meeting  the  costs 
of  illness  and  for  providing  medical  service,  will  be 
worked  out  in  some  states  of  this  country  within  the 
next  few  years.  A  considerable  extension  of  voluntary 
insurance  groups  for  providing  cash  benefits  during 
illness  and  the  expenses  of  medical  service,  may  be 
looked  for,  as  well  as  the  establishment  of  systems 
under  public  auspices. 

Use  of  Funds  for  Medical  Service 

To  what  specific  purposes  are  the  funds  for  ^^financ- 
ing better  medical  service'^  to  be  devoted?  These 
purposes  are  threefold,  so  far  as  the  care  of  illness  is 
concerned : 

1.  The  provision  of  diagnostic  and  therapeutic  equipment, 
in  hospitals  or  in  Dispensaries  of  various  types,  or  in  labora- 
tories. 

2.  The  expenses  of  maintaining  and  administering  the 
equipment  efficiently. 

3.  Most  important  of  all,  the  personal  service  of  physi- 
cians. 

At  the  present  time,  the  responsibility  for  providing 
the  first  and  the  second  rests  (so  far  as  individualistic 
private  practice  is  concerned)  wholly  upon  the  shoulders 
of  the  medical  man.  Since,  as  we  have  seen,  the  in- 
creasing requirements  for  equipment  demand  a  larger 
investment  of  capital  than  the  average  medical  man 
can  meet,  the  consequence  is  that  the  average  physi- 
cian has  to  work,  in  private  practice,  with  an  inade- 


378  DISPENSARIES 

quate  equipment.  The  funds  necessary  for  remedy- 
ing this  deficiency  may  naturally  come,  to  a  consider- 
able degree,  from  the  public  at  large.  Precedents  have 
been  already  established  in  providing  diagnostic 
laboratories.  At  least,  it  may  be  expected  that  the 
purposes  to  which  public  funds  are  devoted,  so  far  as 
public  funds  are  utilized  in  financing  better  medical 
service,  will  tend  to  be  for  the  provision  of  professional 
equipment  and  for  its  administration,  earlier  than  for 
direct  payment  of  personal  services  of  physicians  in 
treating  illness.  The  public  already  does  the  latter, 
but  only  in  cases  of  recognized  dependency,  in  hospi- 
tals, Dispensaries,  or  under  the  charge  of  departments 
dealing  with  the  legally  designated  '^poor."  To  pay 
directly  for  the  personal  services  of  physicians  in 
treating  illness  among  the  population  at  large,  would 
be  state  medical  service,  and  while  many  believe  this 
will  be  the  final  goal  of  medical  development,  it  is  not 
likely  to  be  the  starting-point  of  change  from  the 
present  individualistic  system. 

An  exception  has  already  been  made  in  the  case  of 
contagious  disease,  for  which  most  communities 
provide  treatment  at  public  expense,  and  indeed  in- 
sist upon  it,  unless  satisfactory  private  care  is  known 
to  be  provided.  Tuberculosis  is  rapidly  coming  to  be 
dealt  with  in  the  same  way.  The  venereal  diseases 
may  soon  follow  the  same  course,  particularly  because 
of  the  expensiveness  of  their  effective  treatment. 


FINANCING  SERVICE  379 

Health  Insurance 

Just  as  the  provision  of  equipment  has  been  generally 
regarded  as  the  responsibility  of  the  individual  physi- 
cian, so  the  provision  for  the  physician's  personal 
service,  in  time  of  illness,  has  been  the  responsibility 
of  the  individual  patient.  And  just  as  we  have  seen 
that  the  growing  demand  for  technical  equipment 
renders  the  average  individual  physician  no  longer 
able  to  provide  it  to  an  adequate  extent;  so  we  have 
seen  that  the  growing  cost  and  rising  standards  of 
medical  care  render  it  no  longer  possible  for  the  aver- 
age patient  to  meet  his  needs  as  a  merely  individual 
responsibility.  By  utilizing  the  principle  of  mutual 
insurance,  however,  the  individual  can  continue  to 
bear  a  definite  or  average  share  of  the  burden,  as  a 
self-supporting  member  of  a  group,  and  yet  not  run  the 
risk  of  being  crushed  by  an  undue  weight  at  any  one 
moment.  The  principle  of  insurance  has  a  moral  as 
well  as  an  economic  foundation. 

The  advancement  of  mutual  insurance  under  in- 
dustrial, fraternal,  state,  or  even  commercial  auspices, 
will  obviously  imply  the  expenditure  of  funds  for  the 
personal  services  of  physicians,  in  giving  general 
medical  care;  also  for  cash  benefits  to  the  insured 
person  or  his  family  during  the  period  of  illness  or  of 
incapacity.  The  endeavor  of  mutual  insurance  groups 
to  furnish  adequate  service  to  their  members  should 
lead  to  the  utilization  of  the  methods  of  co-operative 
medical  practice  as  fully  as  possible.  We  already  see 
the  industrial  hospital  and  Dispensary  as  examples. 
They  are  only  beginnings,  for  if  by  co-operative  provi- 


380  DISPENSARIES 

sion  of  equipment  and  medical  organization  a  greater 
efficiency  in  curing  and  preventing  disease  can  be 
attained,  there  is  a  financial  incentive  for  insurance 
groups  to  develop  this  type  of  medical  service. 

Uses  for  Public  Funds 

There  are  two  means  which  we  have  indicated  as 
practicable  for  meeting  the  costs  of  good  medical 
service  for  the  community.  First,  the  provision  of 
funds  by  public  taxation,  which  is  likely  to  advance 
along  the  lines  of  furnishing  diagnostic  facilities  and 
of  establishing  and  maintaining  medical  institutions, 
whose  resources  would  be  available  to  physicians 
generally.  The  provision  of  complete  medical  service 
by  public  funds  is  likely  to  proceed  only  as  demanded 
by  definite  considerations  of  public  health,  in  respect 
to  certain  diseases  or  to  the  peculiar  needs  of  certain 
localities. 

The  lack  of  medical  facilities  in  sparsely  settled 
districts  or  the  proved  needs  of  a  certain  section  of 
a  large  city,  might  cause  extensive  public  provision  of 
medical  facilities  for  these  areas.  The  growing  in- 
terest in  good  obstetrical  service,  for  example,  may 
possibly  lead  to  provision,  by  public  funds,  for  many 
rural  areas  and  for  industrial  districts  in  cities.  In 
such  sections  many  child-bearing  women  now  lack 
adequate  care. 

To   summarize: — 

The  central  principle  by  which  the  cost  of  better  medical 
service  for  the  whole  community  can  be  financed  is  the 
distribution  of  the  burden  of  illness  so  that  this  does  not 


FINANCING  SERVICE  381 

fall  upon  an  individual  or  family  at  the  very  moment 
when  their  ability  to  bear  it  is  less  than  usual.  Such  a 
distribution  of  the  burden  is  not  inconsistent  with  the 
maintenance  of  individual  responsibility  for  self-support, 
or  for  the  payment,  by  the  individual,  of  at  least  his  fair 
average  share  of  the  total  community's  burden.  The 
methods  by  which  the  distribution  can  be  achieved  are 
either  by  mutual  insurance  or  by  public  taxation.  Both 
methods  are  likely  to  be  followed,  each  to  cover  a  portion 
of  the  field. 


382  DISPENSARIES 


CHAPTER  XXIII 

ORGANIZING    DISPENSARY    SERVICE    FOR    A 
COMMUNITY 

The  proportion  of  doctors  to  population  in  the 
United  States  is  about  one  to  every  750  souls.  This 
ratio  is  from  two  to  four  times  as  high  as  that  which 
prevailed  in  most  countries  of  Europe  before  the  War. 
But  such  an  average  figure  covers  wide  variations. 
A  visitor  from  Mars  might  expect  that  at  least  as 
much  medical  service  would  be  required  in  sparsely 
settled  districts  as  in  cities,  in  proportion  to  popula- 
tion, in  fact  rather  more,  because  of  the  greater  dis- 
tances to  be  covered.  But  the  earthly  statistician 
finds  just  the  reverse  to  be  true.  In  not  a  few  large 
cities,  there  is  one  doctor  to  every  350  or  400  people. 
In  rural  sections  the  proportion  is  often  as  low  as  one 
to  every  1,500  or  2,000.  In  many  large  industrial 
communities,  even  in  Eastern  States,  the  ratio  is  not 
over  one  to  1,000.  The  higher  proportions  in  large 
cities  are  due  in  part  to  the  presence  of  many  special- 
ists, and  do  not  therefore  imply  quite  as  wide  a  dis- 
crepancy in  the  ratio  of  general  practitioners;  but  the 
almost  entire  absence  of  specialists  in  rural  districts, 
and  their  very  scanty  presence  in  communities  of 
moderate  size,  is  a  serious  limitation  upon  the  ade- 
quacy of  medical  service.  The  studies  of  the  Federal 
Children's  Bureau  are  showing  how  restricted  are  the 
facilities  for  obstetrical  care  in  the  smaller  communi- 


COMMUNITY  ORGANIZATION  383 

ties,  and  how  unfortunate  are  the  effects.  Those  in- 
terested in  hospitals  are  pointing  out  what  inadequate 
facilities  for  surgical  operation  and  for  hospital  care 
of  grave  medical  diseases,  are  found  as  a  rule  in  the 
small  towns  and  in  agricultural  sections.'*^ 

These  insufficiencies  of  medical  service  are  of  three 
kinds,  between  which  it  is  important  to  discriminate: — 

(1)  An  insufficient  number  of  general  practitioners; 

(2)  Insufficient  diagnostic  and  therapeutic  facilities  for 
the  general  practitioners  to  enable  them  to  do  the  best  work; 

(3)  An  insufficient  number  of  specialists. 

Shortage  of  General  Practitioners 

(1)  The  cause  of  an  insufficient  number  of  general 
practitioners  is  primarily  economic.  A  comfortable 
residential  suburb  has  an  ample  supply  of  doctors. 
A  mill  town  of  the  same  size  has  half  the  number.  Yet 
the  need  of  the  latter  for  general  medical  service  is  if 
anything  greater  than  that  of  the  former. 

If  provision  for  the  education  of  children  were  left 
to  individual  initiative,  we  should  have  a  similar 
situation,  probably  still  more  accentuated  than  in  the 
case  of  medical  service.  We  remedy  the  evil  in  educa- 
tion, to  a  large  extent,  by  public  provision  of  facilities. 
This  means,  essentially,  distributing  the  economic 
burden  over  a  group  sufficiently  large  to  enable  a 
fairly  high  average  standard  of  service  to  be  main- 
tained over  the  whole  area. 

In  medical  service,  as  we  have  pointed  out  in  Chap- 
ter XXII,  the  same  principle  of  distribution  of  the 
economic  burden  must  be  applied  if  the  needs  of  the 


384  DISPENSARIES 

public  are  to  be  met ;  but  it  is  by  no  means  necessary  to 
turn  the  whole  matter  over  to  public  funds.  Other 
ways  and  means  of  ''financing  better  medical  service" 
have  been  already  discussed.  By  one  method  or  an- 
other, or  in  part  by  all  together,  the  distribution  of  the 
economic  burden  must  take  place.  This  will  render 
the  sums  available  for  paying  the  costs  of  medical 
service  bear  a  relation  rather  to  the  number  of  the 
population  than  to  the  presence  of  a  certain  proportion 
of  the  well-to-do.  Need  for  medical  care,  on  the  aver- 
age, varies  in  proportion  to  population.  The  com- 
munity should  see  to  it  that  provision  of  medical  serv- 
ice is  adjusted  in  proportion  to  need. 

Inadequate  Professional  Equipment 

(2)  Physicians  will  not  be  attracted,  however, 
merely  by  the  chance  of  more  certain  remuneration. 
The  professional  facilities  for  medical  study  and  ad- 
vancement, offered  in  the  large  city,  have  substantial 
drawing  power  for  men  of  the  best  type.  The  paucity 
of  diagnostic  and  therapeutic  facilities  in  many 
communities  must  be  remedied.  This  requires  es- 
sentially the  provision  of  institutional,  i.e.,  co-opera- 
tive facilities,  and  means  hospitals,  Dispensaries,  and 
the  enlargement  of  public  health  departments. 

The  funds  secured  for  medical  service  by  public 
appropriation  or  by  mutual  insurance  must  go  in  part 
to  the  direct  payment  of  doctors  for  personal  service, 
and  in  part  to  their  indirect  payment  through  the  co- 
operative provision  of  adequate  technical  equipment 
and  of  means  for  its  efficient  administration  and  upkeep. 


COMMUNITY  ORGANIZATION  385 

Lack  of  Specialists  Outside  of  Cities 

(3)  The  lack  of  specialists  outside  of  the  larger 
centers  must  be  dealt  with  in  a  somewhat  different 
manner,  for  somewhat  different  causes  for  the  defi- 
ciency exist .  In  a  small  community  the  cases  requiring 
an  oculist  or  an  orthopedist  might  not  be  sufficient  to 
keep  him  busy,  even  if  all  were  able  to  pay  the  usual 
rates.  A  certain  town  might  need  only  half  an 
oculist,  but  the  next  town  might  be  too  far  away  for  a 
man  to  practice  conveniently  in  both.  Under  these 
conditions  neither  town  would  have  any  oculist  at  all. 
The  proportion  of  the  population  requiring  specialist 
service  varies  widely  among  the  different  specialties. 
Dentistry  is  a  frequent  and  practically  a  universal 
need.  A  much  smaller  number  of  persons  will,  in  an 
average  year,  need  an  oculist  or  a  surgeon. 

The  specialist  is  even  more  dependent  than  the 
general  practitioner  upon  professional  equipment,  in 
the  way  of  apparatus  and  skilled  assistance.  Co- 
operative provision  and  administration  of  equipment 
is  still  more  necessary,  if  specialists  are  to  be  available 
outside  of  a  few  large  centers ;  and  furthermore,  in  the 
smaller  communities,  some  system  of  visiting  special- 
ists must  be  organized,  when  a  locality  would  require 
only  the  part  time  of  a  man.  This  principle  is  not 
new.  It  has  been  carried  out  in  the  case  of  tubercu- 
losis and  psychiatric  clinics,  with  speciaHsts  visiting  in 
the  smaller  communities  and  holding  clinics  at  stated 
intervals.  The  principle  must  be  much  more  widely 
extended  if  adequate  medical  service  is  to  be  provided 
for  the  whole  people. 


386  DISPENSARIES 

The  City  and  the  Town 

We  have  contrasted  the  large  city  with  the  small 
town,  to  the  disadvantage  of  the  latter  in  respect  to 
medical  service.  The  divergence  in  facilities  is  seen 
to  be  much  less,  however,  through  another  method  of 
comparison.  In  a  town,  most  people  cannot  secure 
specialist  service  because  there  are  no  specialists.  But 
in  a  large  city,  where  specialists  exist  in  plenty,  the 
mass  of  the  population  cannot  obtain  their  services 
except  through  charitable  medical  institutions.  The 
well-to-do  pay  the  specialists  high  enough  fees  to 
enable  them  to  earn  a  living  in  part  of  their  working 
time,  and  to  spend  some  of  the  rest  of  their  time  in 
charitable  practice  among  those  who  are  less  fortunate 
financially.  For  the  middle  classes,  the  self-support- 
ing wage-earners  and  small-business  men,  this  situa- 
tion largely  means,  as  we  have  seen,  that  specialist 
service  is  sought  only  in  case  of  grave  need,  for  these 
people  do  not  wish  to  accept  charity.  The  mass  of 
general  practitioners,  furthermore,  who  work  in  the 
large  city  without  access  to  the  diagnostic  facilities  of 
any  medical  institution,  and  who  have  not  the  means 
to  provide  expensive  equipment  for  themselves,  can- 
not give  their  patients  the  best  of  modern  medicine,  the 
best  that  many  of  them  learned  in  medical  school,  any 
more  than  the  ''country  doctor"  can.  Thus  the 
contrast  between  the  large  city  and  the  small  town  is 
much  less  marked  than  appears  at  first  glance. 

How  shall  we  apply  the  principles  of  ''financing  bet- 
ter medical  service,"  and  the  principles  for  organizing 


COMMUNITY  ORGANIZATION  387 

^Hhe  efficient  Dispensary  of  the  future"  to  the  exist- 
ing Dispensaries,  so  many  of  which  require  help  for 
their  improvement;  and  also  to  new  Dispensaries 
which  should  be  established  where  they  are  needed? 

Modes  of  Improving  Existing  Dispensaries 

The  practical  problem  which  faces  the  typical  chari- 
table Dispensary  now  in  existence  in  the  large  city  is  to 
secure  sufficient  funds  to  provide  adequate  equipment, 
sufficient  administrative  force,  and  in  particular 
salaries  for  its  medical  staff.  Reasonably  good  equip- 
ment is  found  in  a  number  of  institutions  and  ade- 
quate administrative  force  in  a  somewhat  smaller 
proportion.  The  largest  obligation  ahead  is  in  secur- 
ing funds  for  the  staff  salaries. 

Several  measures  maybe  taken  by  such  Dispensaries. 
The  extension  of  Pay  Clinics  is  one  of  them.  These 
may  be  most  readily  started  in  the  specialties,  wherein 
self-support  is  easiest,  medical  opposition  is  practically 
absent,  and  where  a  large  number  of  middle  class 
families  need  a  service  otherwise  quite  beyond  their 
means.  The  problem  of  Pay  Clinics  in  the  specialties 
is  simpler  than  in  general  medicine,  as  has  been  pointed 
out,  but  consultant  service  in  general  medicine  will  be 
found  practicable  under  conditions  wherein  a  treat- 
ment clinic  for  general  cases  might  not  be.  The 
reaction  of  a  number  of  Pay  Clinics  upon  the  medical 
organization  will  be  direct  and  useful.  The  same  staff 
will  probably  be  engaged  in  the  Pay  Chnics  as  in  the 
clinics  charging  nominal  fees  or  no  fees.  The  pay- 
ment of  certain  salaries  for  the  pay-clinic  work,  will 


388  DISPENSARIES 

assist  in  knitting  the  medical  organization  tighter, 
and  in  elevating  clinic  standards  all  along  the  line. 

Establishing  relationships  between  industrial  medi- 
cal work  and  general  charitable  Dispensaries  is  another 
and  more  important  step  in  a  forward  direction.  The 
growth  of  '^compensation  clinics,"  so-called,  accepting 
industrial  accident  cases  under  workmen's  compensa- 
tion laws,  has  already  been  referred  to.  The  develop- 
ment of  industrial  Dispensaries  has  taken  place,  and 
necessarily  must  take  place,  chiefly  in  large  business 
establishments;  but  as  the  movement  for  health  work 
in  industry  advances  and  more  employers  appreciate 
its  business  as  well  as  its  humanitarian  value,  smaller 
firms  will  wish  to  undertake  it.  One  of  the  most 
effective  modes  in  which  they  can  do  so  is  to  make  an 
arrangement  with  a  well-organized  general  Dispensary. 
The  lines  which  such  an  arrangement  could  take  may 
follow  closely  those  already  laid  down  in  the  compensa- 
tion clinics.  Such  service  would  result  in  transferring 
a  considerable  amount  of  free  medical  work  now  under- 
taken by  physicians  as  charity,  to  work  for  which 
remuneration  is  received. 

Next,  general  Dispensaries  may  make  arrangements 
with  mutual  insurance  groups,  now  providing  some 
form  of  medical  care,  for  rendering  service  to  their 
members.  Dispensaries  must  insist  upon  proper 
payment,  both  for  the  medical  salaries  and  the  ad- 
ministrative costs.  Such  arrangements  might  re- 
late to  general  clinics,  or  to  the  specialties  most 
needed  by  the  members  of  the  insurance  group. 

Furthermore,  Dispensaries  should  be  placed  in  the 


COMMUNITY   ORGANIZATION  389 

same  financial  relation  to  public  dependents  as  the 
hospitals.  In  many  cities  and  towns  persons  for 
whose  support  the  public  authorities  are  responsible, 
are  given  medical  service  in  private  hospitals,  which 
are  reimbursed  at  an  agreed  rate  from  the  public 
funds.  In  so  far  as  this  system  of  repayment  to 
hospitals  prevails  in  any  community,  there  is  no  reason 
why  the  same  system  should  not  apply  to  patients  of  a 
similar  class  who  receive  care  in  a  Dispensary  or  out- 
patient department.  It  is  in  fact  illogical  and  unjust, 
that  repayment  should  be  made  in  one  case  and  not 
in  the  other.  The  public  as  a  rule  has  not  yet  fully 
understood  the  prevalence  and  importance  of  Dis- 
pensary care,  or  perhaps  appreciated  that  it  costs 
anything.  Dispensaries  should  be  reimbursed  at  a 
fair  rate  for  the  cost  of  the  treatment  given  to  public 
dependents.  The  rate  of  payment  can  be  readily 
estimated  if  proper  accounts  are  kept.  It  should  as  a 
rule  be  at  a  fiat  rate  for  an  average  visit,  plus  an  agreed 
allowance  for  special  services  like  operations.  X-rays, 
and  medicines.  The  public  authorities  should  make 
such  reimbursements  only  when  the  Dispensary^s 
clinics  are  maintained  at  a  proper  standard. 

Such  a  policy  would  be  of  great  financial  benefit  to 
Dispensaries  and  out-patient  departments,  and  it 
would  further  provide  a  means  for  improving  their 
service,  under  public  inspection  and  supervision. 
Hospitals  and  Dispensaries  should  lay  this  request 
before  the  proper  public  authorities  in  every  commu- 
nity wherein  repayment  for  care  in  private  institu- 
tions on  a  case  basis  is  usual.     To  estabhsh  the  policy 


390  DISPENSARIES 

may  require  some  effort  at  first  but  the  effort  would 
be  worth  while. 

Finally,  the  development  of  public  health  clinics 
will  undoubtedly  extend  into  general  Dispensaries. 
We  already  see  this  in  the  case  of  certain  tuberculosis 
clinics.  It  will  probably  come  about  in  the  case  of 
dental  clinics,  and  in  clinics  treating  syphilis  or  gonor- 
rhea. Provision  by  public  funds  of  equipment,  of 
salvarsan,  or  of  subsidies  for  meeting  the  general  costs 
of  treating  cases  of  venereal  diseases : — these  are  mat- 
ters for  consideration  in  the  near  future.  Similarly 
the  utilization  of  dental  clinics  already  established, 
for  the  purpose  of  treatment  of  mouth  defects  in 
children  on  a  much  larger  scale  than  has  thus  far  been 
undertaken,  must  soon  come  to  be  a  practical  matter 
facing  municipal  bodies. 

In  all  these  five  ways,  and  perhaps  in  others,  exist- 
ing Dispensaries  supported  by  endowment,  or  by 
charitable  contributions,  or  by  both,  should  and  will 
move  towards  the  treatment  of  patients  as  a  public 
service  rather  than  as  a  charity,  and  will  provide 
salaries  for  their  medical  staff  in  growing  measure. 

Some  of  the  strongest  Dispensaries,  particularly 
those  connected  with  medical  schools  or  large  city 
hospitals,  may  secure  funds  through  their  own  efforts, 
sufficient  to  provide  a  permanent  salaried  staff  in  their 
out-patient  departments  and  wards.  But  it  is  much 
to  be  desired  that  even  such  out-patient  departments 
shall  maintain  sufficient  relations  between  their 
working  staff  and  the  general  practicing  profession 
of  their  communities.     The  local  profession  should  not 


COMMUNITY  ORGANIZATION  391 

be  cut  off  from  the  facilities  which  the  out-patient 
department    provides. 

In  a  considerable  number  of  cities  in  this  country, 
particularly  outside  of  the  Eastern  states,  there  are 
but  few  Dispensaries  at  present.  The  number  has 
been  increasing,  and  the  increases  in  the  future  are 
likely  to  proceed  largely  out  of  public  health  or  eco- 
nomic motives.  The  new  Dispensaries  will  often  start 
as  industrial  Dispensaries,  and  we  may  expect  to  see 
such  Dispensaries  round  out  so  as  not  to  limit  their 
service  merely  to  the  employees  in  a  particular  indus- 
try. The  members  of  the  families  of  the  workers  will 
often  come  to  be  included;  nor  need  the  Dispensary 
stop  there.  In  a  community  wherein  the  workers  in  an 
industry  comprise  the  majority  of  the  population,  an 
industrial  Dispensary  might  well  serve  all  the  popula- 
tion, possibly  charging  a  special  fee  to  those  not  em- 
ployed in  the  industry.  Such  industrial  Dispensaries 
will  usually  be  established  with  salaried  medical  staffs. 

We  may  also  look  forward  to  seeing  insurance  groups 
establish  their  own  hospitals  and  Dispensaries,  as  well 
as  make  arrangements  with  existing  institutions.  The 
present  rapid  increase  in  the  number  of  public  health 
Dispensaries  is  certain  to  go  on  and  the  Health  Centers 
will  include  not  only  tuberculosis,  baby  welfare,  prena- 
tal clinics,  and  other  preventive  departments,  but  also 
treatment  clinics,  particularly  in  certain  specialties. 

Community  Organization  of  Dispensaries 

We  have  thus  suggested  several  ways  whereby  the 
financial  and  administrative  program  which  we  have 

26 


392  DISPENSARIES 

outlined  for  Dispensaries  of  the  future  may  practically 
work  itself  out  of  the  existing  situation.  A  further 
problem  is  the  relationship  between  different  types  of 
Dispensaries.  From  the  standpoint  of  a  city  as  a 
whole,  we  may  indicate  three  types : — 

1.  The  Health  Center,  doing  primarily  preventive  work, 
and  entering  into  treatment  work  only  along  certain  rather 
limited  Lines. 

2.  The  District  Dispensary,  as  it  may  be  called,  equipped 
to  do  good  general  Dispensary  work. 

3.  The  Teaching  Dispensary,  providing  facilities  for  the 
diagnosis  of  the  most  difficult  and  rare  cases  and  for  medical 
education  and  research. 

Localization  of  activity  should  be  carried  out  in 
varying  proportion  in  each  of  these  types.  Preventive 
work  must  be  localized  more  than  curative.  The 
public  health  Dispensaries  or  Health  Centers  should 
be  organized  on  a  neighborhood  basis.  Some  health 
officers  regard  a  population  of  perhaps  10,000  as  a 
working  unit  for  a  Health  Center,  but  regard  must  be 
paid  to  area  and  to  congestion  of  population,  some- 
times to  other  local  conditions,  as  well  as  to  mere 
numbers.  Many  of  the  existing  Health  Centers  have 
included  districts  of  from  25,000  to  40,000  persons, 
but  these  have  usually  been  in  congested  areas. 

What  we  have  called  the  District  Dispensary  is 
simply  the  well-organized  and  equipped  Dispensary, 
which  would  ideally  confine  its  work  to  a  given  section 
of  the  city.  In  adapting  an  existing  dispensary  situa- 
tion to  this  principle  of  districting,  many  dijSiculties 
will  be  found.     In  an  immediate  procedure  it  is  at 


COMMUNITY  ORGANIZATION  393 

least  important  to  minimize  the  number  of  Dis- 
pensaries which  are  endeavoring  to  undertake  research 
and  advanced  scientific  work.  In  the  very  largest 
cities  more  than  one  such  institution  may  be  de- 
sirable; in  other  large  communities,  below  the  million 
in  population,  usually  a  single  important  central 
hospital,  in  which  there  is  an  out-patient  department, 
is  all  that  can  and  should  be  equipped  upon  a  scale 
requisite  to  do  the  most  advanced  medical  work. 
Such  an  institution  would  render  diagnostic  service 
on  the  most  difficult  problem  cases  coming  from  the 
community  and  from  its  environs,  perhaps  from  the 
entire  state.  Certain  of  the  state  university  hospitals 
in  the  West  do  this  today.  Such  central  institutions 
must  be  so  related  to  the  other  Dispensaries  and  to 
the  general  medical  profession,  that  the  full  value  of 
the  medical  information  secured  as  a  result  of  the 
study  given  each  case  shall  go  back  to  the  referring 
physician  or  institution,  whether  the  case  is  referred 
merely  for  consultation,  or  for  consultation  and  treat- 
ment. The  existence  of  only  a  single  Teaching  Dis- 
pensary in  a  city  does  not  imply  the  absence  of  all 
medical  teaching  in  the  District  Dispensaries  and 
Health  Centers.  These  should  also  be  used  in  the 
educational  plan;  but  all  as  part  of  one  plan  rather 
than  each  as  an  independent  unit.  Only  thus  can 
the  maximum  economy  of  scientific  and  financial 
resources  be  attained. 

We  have  already  called  attention  to  the  fact  that 
only  a  small  proportion  of  the  medical  profession,  even 
in  those  cities  wherein  out-patient  service  has  devel- 


394  DISPENSARIES 

oped  farthest,  are  on  the  staff  of  the  different  Dis- 
pensaries. The  expansion  of  Dispensary  work  in 
quantity,  and  its  improvement  in  quahty,  faces  a 
practical  difficulty,  due  to  the  fact  that  the  medical 
profession  is  not  homogeneous.  Until  the  rapid  re- 
form in  medical  education  began  in  1909,  a  large 
number  of  commercial  medical  schools  were  turning 
out  annually  numbers  of  poorly  trained  physicians. 
The  number  of  such  medical  schools  has  been  greatly 
reduced  in  the  past  eight  years.  In  1909  there  were 
166  medical  schools  in  the  country;  today  there  are 
less  than  90.  The  reduction  has  been  in  the  com- 
mercial schools  or  in  schools  too  weak  financially  to 
maintain  a  proper  standard.  Much  higher  standards 
in  medical  education  exist  today,  and  they  are  con- 
tinuing to  advance.  But  physicians  who  have  al- 
ready been  licensed  to  practice,  and  who  have  devel- 
oped their  clientele,  will  continue  in  the  profession. 
The  wide  variations  in  skill,  training  and  personality 
which  exist,  raise  difficulties  in  bringing  about  an 
organization  of  medical  institutions  that  would  call 
into  clinic  service  the  entire  local  profession. 

No  one  would  expect  quite  that  stage  to  be  reached. 
The  growth  of  Dispensaries  must,  however,  mean  that 
a  larger  and  larger  proportion  of  the  medical  profes- 
sion is  brought  into  clinic  service.  This  would  be 
greatly  facilitated  not  only  by  the  payment  of  medical 
salaries,  but  also  by  a  growing  comprehension  among 
the  public  of  the  value  of  the  diagnostic  equipment 
which  an  institution  can  provide  and  the  benefits  of 
consultation  and  co-operative  work  among  physicians. 


COMMUNITY  ORGANIZATION  396 

There  is  now  some  prestige  attached  to  membership 
in  the  medical  staff  of  a  hospital  or  Dispensary.  But 
so  long  as  a  majority  of  doctors  are  not  on  these  staffs, 
the  lack  of  such  a  connection  brings  no  stigma  to  a 
physician  in  the  mind  of  the  general  public.  Let  the 
medical  advantages  of  hospitals  and  Dispensaries  be 
more  fully  understood  by  the  public,  and  let  the 
growth  of  hospitals  and  Dispensaries  call  into  service  a 
considerable  majority  of  the  local  profession,  and 
then  the  lack  of  a  staff  connection  will  soon  mean 
the  lack  of  public  confidence  in  a  physician.  If  the 
facilities  of  a  Dispensary  are  to  be  open  ^'to  all  the 
patients  who  need  them  and  to  all  the  doctors  who 
know  how  to  use  them,"  there  must  and  can  be  medical 
standards  of  qualification  which  the  medical  profes- 
sion itself  must  lay  down  and  enforce. 

The  medical  profession  must  in  fact  look  largely  to 
the  Dispensary  as  the  center  wherein  the  continuous 
training  of  its  members  shall  take  place.  Medicine  is 
a  rapidly  progressing  science.  It  is  not  well  that  a 
physician  leave  medical  school,  and  his  interneship  in 
the  hospital,  at  the  age  of  twenty-seven  to  thirty,  and 
pursue  ^'practice"  for  many  years  thereafter,  without 
keeping  abreast  of  advances  in  medical  knowledge  and 
technique.  The  leaders  of  the  profession  and  the 
public  should  and  will  demand  that  there  be  regular 
or  periodical  relationships  between  the  practitioner 
and  centers  of  organized  medical  instruction.  These 
must  be  largely  in  local  Dispensaries.  Lack  of  willing- 
ness to  take  advantage  of  such  opportunities,  as  these 
will  be  offered  in  the  future  through  the  extension  of 


396  DISPENSARIES 

hospital  and  dispensary  facilities,  will  come  to  be  a 
stigma  upon  a  physician.  It  is  not  too  much  to 
expect  that  the  public  authorities  controlling  the 
licensing  and  practice  of  medicine  will  ultimately  re- 
quire that  such  opportunities  be  provided  and  utilized. 

How  shall  this  program  for  dispensary  development 
be  adapted  to  the  city  of  moderate  size  or  to  the  town? 
Communities  of  this  size  cannot  and  should  not  expect 
to  maintain  a  Teaching  Dispensary.  They  do  need 
the  general  or  District  Dispensary  and  they  need  the 
Health  Center  in  due  ratio  to  their  population  and 
their  health  problems.  In  fact  we  may  readily  work 
out  the  dispensary  organization  of  a  middle-sized 
community  by  considering  that  it  is  a  section  of  a 
large  city.  The  problem  in  the  two  is  not  quite  the 
same,  but  the  difference  is  chiefly  in  details. 

In  small  towns  the  problem  of  securing  efficient 
specialist  service  arises  and  in  the  country  this  becomes 
serious.  In  rural  districts  the  Dispensary  may  be 
peripatetic.  There  would  not  be  enough  people  to 
require  a  daily  or  even  a  tri- weekly  clinic,  nor  would 
local  funds  be  sufficient  to  support  these.  The  finan- 
cial burden  must  in  fact  be  distributed  over  a  wider 
area,  the  county  or  the  State.  It  may  often  be  neces- 
sary that  the  Health  Centers  in  a  district  be  supported, 
at  least  in  part,  by  state  funds.  In  the  present  pro- 
gram of  the  British  Local .  Government  Board  for 
treatment  of  venereal  diseases,  three-quarters  of  the 
expense  of  the  clinic  services  is  to  be  borne  by  the 
central  authorities  and  one-quarter  by  the  locality. 
Whatever   the   ratio   of   distribution,    there   is   little 


COMMUNITY  ORGANIZATION  397 

doubt  that  the  provision  of  adequate  equipment,  for 
preventive  work  and  for  certain  most  needed  forms 
of  curative  service,  must  largely  come  from  other  than 
local  funds  in  the  sparsely  settled  districts.  Very  likely 
the  services  of  specialists  holding  clinics  at  regular 
intervals  must  be  paid  at  least  in  part  from  funds  se- 
cured by  taxation  from  a  wider  area  than  the  imme- 
diate vicinity.  Dental  specialists  might  be  required 
weekly  or  bi-weekly  in  a  town  wherein  an  oculist  or 
laryngologist  might  come  once  a  week,  and  a  neurolo- 
gist, psychiatrist  or  orthopedist  fortnightly. 

The  reorganization  and  expansion  of  Dispensaries, 
and  such  state-wide  or  community  planning  as  we 
have  suggested,  obviously  face  many  difficulties. 
Paramount  among  these  are  the  highly  individualistic 
character  of  the  medical  profession  and  the  small 
public  comprehension  of  the  nature  and  possibilities 
of  modern  medical  science.  The  medical  profession  is 
by  tradition  a  body  of  individual  practitioners,  each 
working  on  his  own  hook.  The  doctor's  chief  train- 
ing in  the  past  has  been  in  dealing  with  individual 
patients.  He  has  not  been  trained  to  think  in  terms 
of  public  or  community  problems.  The  growth  of 
public  health  work  and  the  training  of  a  certain  num- 
ber of  medical  men  for  public  health  service  has  as 
yet  changed  the  situation  but  slightly.  A  greater 
effect  has  been  produced  in  recent  years  through  the 
prevalence  of  interneships  in  hospitals.  A  period  of 
residence  as  an  interne  in  a  hospital  is  now  a  practical 
necessity  for  the  recent  graduate  of  a  medical  school, 
and  this  period  gives  to  the  young  medical  man  a 


398  DISPENSARIES 

training  in  organization,  in  working  as  part  of  a  sys- 
tem. To  some  extent  we  may  count  on  this  new  ele- 
ment in  medical  training  to  create  greater  readiness 
and  ability  on  the  part  of  physicians  to  extend  co- 
operative practice.  Military  service  will  perhaps  have 
a  similar  influence. 

Such  changes  in  the  point  of  view  of  a  great  profes- 
sion are  necessarily  slow.  The  medical  profession 
must  frankly  face  the  changes  which  medical  science 
is  bringing  upon  medical  practice.  The  leaders  in  the 
medical  profession  bear  the  responsibility  of  making  the 
rank  and  file  understand  that  there  is  now  a  scientific 
necessity  for  the  co-operative  provision  of  diagnostic 
equipment,  and  of  facilities  for  reception  and  care 
of  patients,  and  that  there  must  consequently  follow 
a  large  development  of  co-operative  medical  service 
through  various  forms  of  institutional  organization. 
Individualism  in  medicine  should  continue,  so  far  as  it 
implies  a  sense  of  direct  responsibility  for  the  patient, 
but  individualism  must  not  be  and  cannot  continue  to 
be  in  antagonism  to  working  as  part  of  an  organiza- 
tion, with  graded  responsibilities  established  therein. 
We  may  be  confident  that  whatever  is  clearly  demanded 
by  the  public  interests  as  a  whole,  should  and  will 
over-ride  the  special  interests  of  any  vocation  or 
group;  and  also  that  there  lies  ahead  of  the  medical 
profession  a  future  of  enlarged  dignity  and  of  more 
secure  economic  remuneration,  if  there  is  a  broad  com- 
munity organization  of  the  wonderful  resources  of 
medical  science  and  of  the  skill  of  its  representatives 
in  the  medical  profession, — an  organization  such  as 


COMMUNITY  ORGANIZATION  399 

will  render  the  very  best  of  these  resources  accessible 
to  all  the  people  on  a  democratic  basis.  The  great 
War  is  calling  to  everyone's  attention  the  power  of 
medicine  to  prevent  disease  among  great  masses  of 
individuals  whose  countries  were  swept  by  pestilence, 
and  to  heal  wounds  and  illness  among  the  victims  of 
the  battlefield  as  these  have  never  been  healed  before. 
The  public  will  not  fail  to  remember,  however,  that 
these  wonders  have  been  accomplished  by  organized 
rather  than  by  individualistic  medicine. 


400  DISPENSARIES 


CHAPTER  XXIV 
CONCLUSION 

In  the  preceding  chapters  we  have  endeavored  to 
help  those  who  are  concerned  with  the  practical  man- 
agement of  Out-Patient  Departments  and  Dispen- 
saries, and  also  to  point  the  way  towards  their  devel- 
opment as  agents  of  larger  service  to  the  people. 

Dispensaries  must  now  be  conducted  under  the 
unusual  conditions  created  by  the  War.  The  short- 
age in  medical  staffs,  the  high  cost  of  supplies,  and 
the  financial  uncertainty  of  the  times,  raise  many 
difficult  problems.  Yet  despite  these  conditions, 
Dispensaries  should  not  stand  still,  much  less  retro- 
grade. They  should  advance.  They  can  advance, 
given  some  vision  and  a  little  courage.  The  imme- 
diate responsibility  of  the  trustees,  physicians,  and 
superintendents  of  Dispensaries  and  Out-Patient 
Departments  is  to  adapt  their  work  so  as  to  meet  more 
fully  and  more  effectively  the  present  needs  of  their 
communities.  Certain  needs  are  increased  because 
of  the  War,  or  will  be  recognized  more  fully  by  the 
public  because  of  the  mental  quickening  of  these 
stirring  years. 

For  example,  the  improvement  of  existing  clinics 

treating  syphilis  and  gonorrhea,  and  the  establish- 

/   ment  of  many  more  such  clinics,  is  no  longer  the 

I    endeavor  of  a  few  especially  interested  individuals, 


CONCLUSION  401 

but  has  become  a  great  national  program.  The 
conservation  of  infant  Hfe  and  of  motherhood  looms 
larger  in  the  public  eye  than  ordinarily,  and  this  should 
lead  to  the  advancement  of  children's  and  women's 
clinics,  and  to  numbers  of  new  public  health  clinics 
for  mothers  and  babies.  Again,  since  the  production 
of  food,  fuel,  munitions  and  War  supplies  must  be 
maintained  at  a  maximum,  and  expedited  to  the 
utmost,  in  addition  to  the  necessary  manufactures 
for  the  civilian  population,  the  care  of  the  health  of 
the  workers  is  a  vital  element  in  national  efficiency. 
So  far  as  Dispensaries  are  to  render  this  care, — and 
in  large  industrial  sections  they  must  supply  a  great 
deal  of  it, — it  is  important  that  clinics  should  inter- 
fere as  little  as  possible  with  the  usual  working  hours. 
The  loss  in  wages  to  the  workers,  and  in  output  of 
product  to  the  community,  is  of  itself  more  than 
sufficient  to  pay  the  additional  expense  of  clinics  in 
the  evenings  or  late  afternoons.  These  are  a  neces- 
sary part  of  the  War  program  for  maximum  national 
efficiency. 

In  times  of  peace  as  well  as  war,  such  practical 
economic  service  of  Dispensaries  furnishes  a  sound 
basis  of  appeal  to  business  men  for  financial  support. 
The  managers  of  Dispensaries  and  out-patient  depart- 
ments will  do  well  to  bear  in  mind  also,  that  a  period 
when  employment  is  general,  is  favorable  for  the 
development  of  fee  systems  in  Dispensaries,  from 
which  a  considerable  proportion  of  the  expenses  can 
be  met  without  interference  with  charitable  service. 

A  patient  in  a  hospital  is  taken  out  of  the  com- 


402  DISPENSARIES 

munity  for  the  nonce.  A  patient  of  a  Dispensary 
retains  his  normal  social  relationships  and  in  many 
instances  his  earning  power.  When  Dispensary  treat- 
ment is  practicable,  it  is  a  moral  advantage  and  an 
economic  gain.  The  War-time  campaign  for  the 
'^reconstruction  of  soldiers''  should  rest  upon  the 
Dispensary  principle  rather  than  the  hospital  principle, 
so  far  as  medically  possible.  This  campaign  is  in 
any  case  familiarizing  the  public  with  the  idea  of 
after-care  and  of  vocational  readjustment,  following 
surgical  operations,  accidents,  or  acute  medical  dis- 
eases. As  the  humanity  and  economy  of  after-care 
becomes  more  apparent  to  hospital  authorities,  busi- 
ness men,  and  patients  themselves,  the  lack  of  Dis- 
pensary facilities  in  any  community,  or  for  any  hos- 
pital doing  public  work,  will  be  regarded  as  a  serious 
if  not  an  incriminating  deficiency. 

The  development  of  Dispensaries,  as  prefigured  in 
this  book,  must  take  place  partly  as  a  result  of  internal 
forces.  The  trustees,  physicians  and  superintend- 
ents of  existing  institutions  will  strive  to  increase 
efficiency  and  improve  technique.  But  with  Dis- 
pensaries, as  with  other  organizations,  the  impulses 
which  set  internal  forces  in  operation  are  chiefly  some 
stimulation  from  outside. 

The  more  that  charitable  and  benevolent  societies, 
fraternal  orders,  churches,  and  civic  associations  are 
interested  in  health;  the  more  that  the  scope  and 
powers  of  health  departments  are  widened;  the  more 
that  the  general  public  thinks  and  understands  about 
health  problems;  so   much  the    more    forcibly    will 


CONCLUSION  403 

stimuli  to  improvement  penetrate  the  institutional 
shells  of  Dispensaries  and  hospitals,  and  so  much  the 
more  readily  will  financial  support  be  secured.  The 
growing  recognition  by  great  managers  of  industry 
that  the  care  of  the  health  of  the  workers  is  a  practical 
asset,  is  another  powerful  impelling  force  towards 
the  development  of  existing  Dispensaries  and  the 
establishment  of  new  ones. 

The  relation  between  the  Dispensaries  and  the 
hospitals  is  of  vital  importance.  The  establishment 
of  an  out-patient  department  brings  a  hospital  into  a 
more  extensive  and  varied  contact  with  the  commu- 
nity, and  the  rapid  increase  of  out-patient  departments 
in  recent  years  may  be  taken  as  an  encouraging  indi- 
cation that  our  hospitals  are  becoming  more  responsive 
agents  of  pubHc  service.  The  further  advance  of 
Dispensaries  will  continue  to  react  beneficially  upon 
the  hospitals,  for  hospitals  need  improvement  not 
only  in  technical  standards  of  management,  and  in 
those  relations  with  the  medical  staff  in  which  the 
American  College  of  Surgeons  is  especially  interested, 
but  also  in  the  broader  aspects  of  policy.  An  inquiry 
such  as,  ^^What  shall  a  hospital  do  to  increase  its 
efficiency?'^  is  largely  an  institutional  question.  The 
inquiry,  ''What  can  the  hospital  do  to  increase  its 
service  to  the  community? '^  involves  the  former 
query  as  one  element,  but  also  much  wider  consid- 
erations of  pubhc  health  and  social  policy.  The 
Dispensary  is  part  of  the  answer  to  the  second  ques- 
tion. 

More  adequate  facilities  for  medical  care  in  the 


404  DISPENSARIES 

small  towns  must  be  kept  in  the  foreground  of  any 
general  health  program,  and  this  means  the  estab- 
lishment of  local  clinics  and  of  public  health  Dispen- 
saries. The  War  renders  the  conservation  of  life, 
the  promotion  of  health,  more  important  than  ever 
before.  The  War  is  bringing  the  public  to  realize 
this  as  never  before.  The  health  of  the  productive 
workers  of  today,  and  of  the  mothers  and  the  children, 
is  the  foremost  element  in  the  vital  efficiency  of  the 
nation,  and  one  of  the  chief  items  in  its  War-time 
productive  efficiency.  Health  is  now  realized  to  be 
not  only  an  individual  but  a  national  asset.  The 
care  of  health  is  not  only  an  individual,  but  a  public 
responsibility.  Provision  for  the  care  of  health 
need  not  remove  initiative  or  responsibility  from 
the  shoulders  of  the  individual,  but  it  can  no  longer 
be  left  solely  to  the  individual's  efforts.  The  care  of 
sickness  and  the  promotion  of  health  must  be  organ- 
ized as  conscious,  co-operative  undertakings,  or  as 
undertakings  of  the  community  itself  through  gov- 
ernmental agencies. 

Public  understanding  of  the  power  of  modern  med- 
icine and  of  the  nature  of  modern  medical  work  grows 
but  slowly.  This  is  partly  because  doctors  have  not 
taken  the  public  sufficiently  into  their  confidence,  and 
partly  because  of  the  very  rapid  growth  of  modern 
medicine  itself,  which  has  kept  far  ahead  of  its  in- 
terpretation to  the  general  public.  The  grown  men 
of  today  received  their  first  impressions  of  medicine 
largely  at  a  time  when  modern  medicine  was  just 
beginning  to  exist.     It  takes  about  a  generation  to 


CONCLUSION  405 

make  such  a  change  understood  by  the  public  as  a 
whole.  It  is  more  important  that  the  public  under- 
stand about  medicine  than  about  astronomy  or  engi- 
neering, because  the  health  of  the  public  is  directly 
at  stake.  The  people  need  to  know  what  co-operative 
practice  means,  how  great  the  need  is  for  modern 
equipment  in  medicine,  for  adequate  service  of  special- 
ists and  for  preventive  work.  For  the  education  of 
the  public  we  must  rely  partly  on  the  writers  and 
popularizers  of  scientific  development,  and  partly 
upon  the  growth  of  health  departments  and  medi- 
cal institutions  themselves,  as  they  extend  their 
service  through  wider  and  wider  sections  of  the  com- 
munity. In  proportion  as  they  are  democratic  and 
efficient  will  their  work  be  understood,  appreciated  and 
advanced. 

The  tendencies  of  the  War  period  are  in  favor  of 
this  development.  But  the  nature  and  methods  of 
modern  medical  service  must  be  popularized.  Volun- 
tary associations,  health  departments,  journals,  news- 
papers, writers,  social  workers  and  the  leaders  of  the 
medical  profession,  must  direct  their  efforts  largely 
toward  this  fundamental  pubHc  education.  The 
moral  and  financial  foundation  of  all  public  and  private 
health  work,  as  well  as  of  hospitals  and  Dispensaries, 
must  be  broad  popular  knowledge  and  democratic 
support. 


406  DISPENSARIES 


^ 


BIBLIOGRAPHY 

Citations  in  the  text  are  indicated  by  small  numbers, 
which  refer  to  books  or  articles  indicated  by  corresponding 
numbers  below.  An  additional  list  of  selected  references, 
grouped  by  topics,  is  appended.  The  classification  accord- 
ing to  subject  is  rough,  and  for  purposes  of  convenience 
only,  since  many  articles  treat  of  more  than  one  topic. 

1  TJie  First  London  Dispensaries.  By  a  Surgeon  (probably  H.  N. 
Hardy).     Fraser's  Magazine,  May,  1875,  Vol.  XI:  pp.  598-607. 

2  A  History  of  The  Boston  Dispensary.  Compiled  by  one  of  the  Board 
of  Managers  (Wniiam  R.  Lawrence).  Not  Published.  Printed  by 
John  Wilson  &  Son,  22  School  Street,  Boston,  1859. 

'  Page  140  of  work  just  cited. 

*  Osier,  Dr.  William,  Remarks  on  the  Functions  of  an  Out-Patient 
Department.  British  Medical  Journal,  June  20,  1908,  Vol.  I  for  1908, 
p.  1470. 

6  Cabot,  Dr.  Richard  C.  Suggestions  for  the  Reorganization  of  Out- 
Patient  Departments,  with  Special  Reference  to  the  Improvement  of  Treat- 
ment.    Maryland  Medical  Journal,  March,  1907,  Vol.  L:  p.  81. 

6  Goldwater,  Dr.  S.  S.  Dispensary  Ideals.  American  Journal  of 
the  Medical  Sciences  (1907),  New  Ser.,  Vol.  134:  p.  313. 

'  Davis,  Michael  M.,  Jr.  Efficiency  Tests  of  Out-Patient  Work. 
Boston  Medical  and  Surgical  Journal,  June  20,  1912. 

8  Associated  Out-Patient  CHnics  of  New  York.  First  Annual  Report, 
1913.     17  West  43d  Street,  New  York.     Also  later  Reports. 

^Report  of  Committee  on  Out-Patient  Work.  American  Hospital 
Association,  in  Proceedings  of  the  Association,  1914,  p.  312. 

^0  Quoted  with  modifications  from  Davis,  Michael  M,,  Jr.,  The  Func- 
tions of  a  Dispensary  or  Out-Patient  Department.  Boston  Medical  and 
Surgical  Journal,  August  27,  1914. 

11  Report  of  Committee  on  Oui-Patient  Work.  American  Hospital 
Association  in  Proceedings  of  Association,  1916,  pp.  102  et  seq. 

^  Shrady,  Dr.  George  F.  A  Propagator  of  Pauperism:  The  Dia- 
pmsary.    The  Forum  (1907),  Vol.  23:  p.  420. 


BIBLIOGRAPHY  407 

1'  Thayer,  Dr.  W.  S.     Report  on  Dispensary  Abuse,  by  Committee  of 
the  Medical  and  Chirugical  Faculty  of  Maryland.     Maryland  Medical 
Journal  (J907),  Vol.  L:  p.  277.     Also  summary  in  Journal  of  the  Amer- 
'"''ican  Medical  Association  (1907),  Vol.  49:  p.  792. 

^*  Savage,  Charles  C.  Dispensaries  Historically  and  Locally  Con- 
sidered. International  Conference  of  Charities,  Correction  and  Phil- 
anthropy (1893),  p.  630. ' 

^'  Janeway,  Dr.  Theodore  C.     The  Social  Evolution  of  a  Dispensary.       ^^ 
Charities    (1907),    Vol.    17:  p.    863.     Kirkbride,    Franklin   B.    Some 
Phases  of  the  Dispensary  Problem.     Annals  of  the  American  Academy       ^ 
(1904),  Vol.  23:  p.  424.     Kleene,  G.  A.     The  Problem  of  Medical  Char- 
ity, Vol.  just  cited,  p.  409. 

1^  Gay,  Dr.  George  W.  and  Others.  Symposium  on  Dispensary 
Abuse.  Boston  Medical  and  Surgical  Journal  (1905),  Vol.  152:  pp. 
295-314. 

^^  The  Movement  in  Chicago  for  the  Regulation  and  Improvement  of 
Institutional  Medical  Charity.  (Pamphlet.)  Issued  by  the  Committee 
on  the  Abuse  of  Medical  Charity,  Chicago  Medical  Society,  November, 
1910. 

18  Report  of  the  Committee  on  Dispensary  Abu^e  of  the  Medical  Society 
of  the  County  of  New  York.  New  York  State  Journal  of  Medicine  (Jan- 
uary 1913),  Vol.  XIV:  No.  1,  p.  48. 

1'  Boston  Dispensary,  Annual  Reports,  1911  et  seq.  Summary  in: 
Davis,  Michael  M.,  Jr.,  A  Medical  Bugbear:  Dispensary  Abuse.  The 
Medical  Record,  September  12,  1914  (contains  a  bibliography). 

2°  Veeder,  Dr.  Borden  S.  Standards  for  Determining  the  Suitability 
of  Patients  for  Admission  to  a  Free  Dispensary.  Journal  of  the  American 
Medical  Association  (1916),  Vol.  67:  p.  95. 

^1  Jobes  and  Hostetter.  Social  Survey  of  Dispensary  Patients  in 
Philadelphia.    The  Modem  Hospital  (1914),  Vol.  5:  p.  321. 

^  Thornton,  Janet.  The  Place  of  Medical  Care  in  a  Workingman'g 
Budget.     Boston  Dispensary,  Annual  Report,  1915,  p.  43. 

2'  Report  of  the  Social  Insurance  Commission  of  the  State  of  California. 
January,  1917.    P,  43. 

'*  Report  of  the  Social  Insurance  Commission  of  the  Commonwealth  of 
Massachusetts.    January,  1918.     Pp.  142-158. 

"  Warner,  Dr.  A.  R.     Dispensary  Abuse  and  its  Eliminaiion  by  the 
Application  of  Sociologic  Methods.    Journal  of  the  American  Medical 
Association  (1913),  Vol.  60:  p.  738. 
27 


^ 


408  DISPENSARIES 

2«  Davis,  Michael  M,,  Jr.  Present  Status  and  Problems  of  Out-Patient 
Work.     Proceedings  of  American  Hospital  Association  (1913),  p.  316. 

2^  Valentine,  Robert  G.  Application  of  the  Principles  of  Organization 
to  Hospital  Service.     The  Modern  Hospital,  April,  1916,  p.  262. 

28  Thomson,  Dr.  Alec  N.  The  Genito-Urinary  Department  of  the 
Brooklyn  Hospital  Dispensary.     Social  Hygiene,  January,  1916,  p.  91. 

29  Day,  Dr.  Hilbert  F.  Bridging  a  Gap  in  Out-Patient  Service.  Bos- 
ton Medical  and  Surgical  Journal,  March  2,  1916. 

30  Davis,  Michael  M.,  Jr.  The  Efficiency  of  Out-Patient  Work.  Jour- 
nal of  the  American  Medical  Association,  November  8,  1912.  The 
reference  made  in  the  course  of  this  citation  is  to  an  article  by  Drs.  F.  J. 
Cotton  and  R.  J.  O'Neil  in  Boston  Medical  and  Surgical  Journal  (1903) 
Vol.  149:  p.  538. 

'^  Report  of  the  Committee  of  Inquiry  into  the  Departments  of  Health, 
Charities,  and  Bellevue  and  Allied  Hospitals  in  the  City  of  New  York, 
appointed  by  the  Board  of  Estimate  and  Apportionment,  1913.  Section 
VII,  Care  of  Out-Patients,  pp.  5-18. 

"  Same  reference  as  No.  26. 

^  Presbyterian  Hospital  in  the  City  of  New  York.  Annual  Report, 
1915. 

^  Portions  of  this  Chapter  are  quoted  with  modifications  from  three 
articles  by  Davis,  Michael  M.,  Jr.,  (1)  Dispensaries  for  the  Smaller 
Hospitals:  Why  We  Need  Them?  The  Trained  Nurse  and  Hospital 
Review,  54  (1915),  p.  323.  (2)  How  to  Organize  and  Manage  Them. 
Ibid.  55  (1915),  p.  1.  (3)  Dispensaries  vnthout  Hospitals.  Ibid.  55 
(1915),  p.  139. 

^  Quoted  with  modification  from:  Davis,  Michael  M.,  Jr.,  The  Bene- 
ficial Results  of  Prenatal  Work.  Boston  Medical  and  Surgical  Journal, 
January  4,  1917. 

^  Wilhams,  J.  Whitridge.  Journal  of  the  American  Medical  Associa- 
tion, January  9,  1915. 

"  Davis,  Michael  M.,  Jr.  What  the  Campaign  Against  Venereal 
Disease  Demands  of  Hospitals  and  Dispensaries.  American  Journal  of 
Public  Health,  April,  1916,  p.  346. 

'*  Report  of  Committee  on  Social  Insurance  of  the  Council  on  Health 
and  Public  Instruction,  American  Medical  Association.  Journal  of  the 
American  Medical  Association,  June  9,  1917,  p.  1752.  Also  Davis, 
Michael  M.,  Jr.  A  Report  on  Dispensaries  in  Massachusetts  in  the  Re- 
port of  the  Massachusetts  Social  Insurance  Commission,  1918,  p.  142. 

"  (a)  Chapin,  Robert  Coit.     The  Standard  of  Living  among  Working- 


BIBLIOGRAPHY  409 

merits  Families  in  New  York  City.  N.  Y.  Charities  Publication  Com- 
mittee, 1909.  (b)  New  York  Factory  Investigating  Commission. 
Fourth  Report,  1915.  Vol.  IV.  Appendix  VII,  pp.  1461-1844.  The 
Cost  of  Living  in  New  York  Staie. 

*°  State  Charities  Aid  Association,  New  York.  Sickness  in  Dutchess 
County,  New  York.     Its  Extent,  Care  and  Prevention.     September,  1915. 

Topical  References 
Historical 

Vide  Numbered  References  (1)  and  (2). 

U.  S.  Bureau  of  the  Census.  Special  Report  on  Benevolent  Institu- 
tions, 1904. 

Ihid.     Report  on  Benevolent  Institutions,  1910. 

American  Hospital  Association,  Reports  of  Committee  on  Out-Patient 
Work.  Proceedings  of  the  Association,  1913  (p.  316);  1914  (p.  312); 
1915  (p.  416);  1916  (p.  102). 

Anon.  Medical  Charity:  Its  Extent  and  Abuse.  Westminster  Review 
(1874),  Vol.  101:  pp.  174,  464. 

Anon.  Self-Supporting  Dispensaries.  The  Penny  Magazine,  June 
21,  1834,  Vol.  3:  p.  238. 

Davis,  Michael  M.,  Jr.  The  Boom  in  Dispensary  Work.  Modern 
Hospital,  August,  1914. 

Goldwater,  Dr.  S.  S.  Dispensaries:  A  Factor  in  Curative  and  Pre- 
ventive Medicine.     Boston  Medical  and  Surgical  Journal,  April  29,  1915. 

Lewinski-Corwin,  E.  H.  The  Associated  Out-Patient  Climes  of  New 
York:  A  Social  Force.     N.  Y.  Medical  Record,  February  15,  1913. 

Trevelyan,  Sir  Charles.  On  the  Extension  of  Provident  Dispensaries 
throughout  London  and  its  Environs.  Pamphlet  issued  by  Charity 
Organization  Society  of  London,  1878. 

Winslow,  C.-E.  A.  Public  Health  Administration  in  Russia  in  1917 
(Russian  Dispensary  System).  In  U.  S.  PubHc  Health  Reports, 
December  28,  1917,  pp.  2191  et  seq. 

Social  and  Economic  Status  of  Dispensary  Clientele 

Vide  Numbered  References  12  to  25  inclusive;  also  39  and  40.  For 
Special  BibUography  see  in  Numbered  Reference  19. 

Committee  on  Dispensary  Abu^se  of  the  Academy  of  Medicine  of  Cleve- 
land, Ohio.    Report,  1912.     Cleveland  Medical  Journal,  11:  p.  126. 

Cobb,  Dr.  Farrar.  The  Regulation  of  Medical  Charity.  Boston 
Medical  and  Surgical  Journal,  152  (1905) :  p.  307. 


410  DISPENSARIES 

Foster,  E.  C.  The  Chanties  Clearing  House  in  its  Relation  to  Dispen- 
sary and  Hospital  Abuse.     Cleveland  Medical  Journal,  10  (1911) :  p.  818. 

Warner,  Dr.  A.  R.  The  Sources  of  Dispensary  Abuse.  Cleveland 
Medical  Journal,  10  (1911):  p.  833. 

Washburn,  Dr.  F.  W.  Medical  Charity  at  the  Massachusetts  General 
Hospital.    Boston  Medical  and  Surgical  Journal,  152  (1905) :  p.  309. 

Williams,  Dr.  J.  Whitridge.  Dispensary  Abuse  and  Certain  Problems 
of  Medical  Practice.  Journal  of  the  American  Medical  Association, 
July  8,  1916. 

Social  Service 

Annual  Reports  of  existing  Social  Service  Departments,  particularly 
the  Massachusetts  General  Hospital;  Bellevue  Hospital,  N.  Y.;  Medical 
School  of  the  University  of  Indiana;  Boston  City  Hospital;  Psychopathic 
Hospital,  Boston;  Boston  Dispensary. 

Annual  Reports  of  New  York  School  of  Philanthropy  and  of  Boston 
School  of  Social  Work. 

Briggs,  Dr.  L.  Vernon.  Three  Months  With  and  Three  Months  With- 
out a  Social  Worker  in  the  Mental  Clinic  at  the  Boston  Dispensary.  Amer- 
ican Journal  of  Insanity,  October,  1912. 

Cabot,  Dr.  Richard  C.  Social  Service  and  the  Art  of  Healing.  N.  Y. 
1909. 

Cannon,  Ida  M.  Social  Work  in  Hospitals.  Russell  Sage  Founda- 
tion, 1912. 

Davis,  Michael  M.,  Jr.  Social  Aspects  of  a  Medical  Institution. 
Proceedings,  National  Conference  of  Charities  and  Correction,  1912, 
p.  363.  Ibid,  Social  Diagnosis.  Medical  Review  of  Reviews,  June, 
1912. 

Richards,  Ehzabeth  V.  H.  Social  Service  in  an  Out-Patient  Depart- 
ment.   Proceedings  of  the  American  Hospital  Association,  1913,  p.  412. 

Wilson,  Mabel  R.  and  Davis,  Michael  M.,  Jr.  A  New  Minister  to 
Minds  Diseased.    The  Survey,  April  5, 1913. 

Williams,  Dr.  Linsley  R.  The  Value  of  the  Social  Worker  and  Visiting 
Nurse  to  the  Dispensary  Patient.  N.  Y.  Medical  Journal,  87  (1908): 
p.  143. 

Buildings,  Equipment,  Organization 

Vide  Numbered  References  5  to  11  inclusive. 

"The  Function  of  the  Dispensary."  Report  of  Committee  of  Associa- 
tion of  American  Medical  Colleges,  Dr.  George  Blumer,  chairman. 
Journal  of  the  American  Medical  Association,  66  (1916):  1156. 


BIBLIOGRAPHY  411 

Cabot,  Dr.  Richard  C.  Why  Should  Hospitals  Neglect  the  Care  of 
Chronic  Curable  Disease  in  Out-Patients?  St.  Paul  Medical  Journal, 
March,  1908. 

Camac,  Dr.  C.  N.  B.  The  Out-Patient  Clinic:  Its  Aims  and  Possi- 
bilities. Canadian  Journal  of  Medicine  and  Surgery.  Vol.  32  (1912): 
No.  1. 

Hornsby,  Dr.  John  A.  and  Schmidt,  Richard  E.  The  Modern  Hos- 
pital.    (Saunders)  1913. 

Klaer,  Dr.  Fred  H.  Methods  and  Efficiency  in  Medical  Out-Patient 
Work.     American  Medicine,  June,   1914. 

McLean,  Dr.  Stafford.  Suggested  Improvements  for  Medical  Out- 
Patient  Work  with  Children.     Archives  of  Pediatrics,  March,  1917. 

Massachusetts  General  Hospital.  Anniuil  Report,  1915,  Sec.  B,  pp. 
32-38. 

Peter  Bent  Brigham  Hospital.     Annual  Report,  1916,  pp.  134  et  seq. 

Smith,  Dr.  James  H.  The  Free  Dispensary  as  a  Municipal  Health 
Agency.  Bulletin  of  the  Medical  College  of  Virginia,  12  (1915):  No. 
3,  p.  3. 

Reports  of  Committee  on  Out-Patient  Work,  American  Hospital  Asso- 
ciation.    Vide  supra. 

Follow-Up  Systems  and  Efficiency  Tests 

Vide  Numbered  References  7,  29,  30  and  31. 

Barringer,  Dr.  B.  S.  A  Survey  of  Venereal  Clinics  in  New  York  City, 
and  Piatt,  Philip  S.,  A  Statistical  Efficiency  Test.  National  Conference 
of  Charities  and  Corrections,  1915,  p.  281. 

Barron,  Dr.  Elmer  W.  and  Davis,  Michael  M.,  Jr.  A  Follow-Up 
System  for  Promoting  Efficiency  in  an  Out-Patient  Clinic.  Boston  Med- 
ical and  Surgical  Journal,  December  4,  1913. 

Codman,  Dr.  E.  A.     A  Study  in  Hospital  Efficiency.     Boston,  1917. 

Committee  on  Hospital  Efficiency  of  the  Philadelphia  County  Medical 
Society.  Reports  Submitted  June  17,  1913;  November  26,  1913;  and 
October  21,  1914.     (Pamphlets.) 

Corscaden,  Dr.  James  A.  The  Follow-  Up  System  of  the  Presbyterian 
Hospital  in  the  City  of  New  York.  Journal  of  the  American  Medical 
Association,  March  11,  1916. 

Hartshorn,  Dr.  Edward  and  Davis,  Michael  M.,  Jr.  Follow-Up 
Work  as  an  Element  of  Effective  Treatment  in  an  Out-Patient  Clinic  for 
Eye  Diseases.     Boston  Medical  and  Surgical  Journal,  April  11,  1913. 

Langstroth,  Dr.  Lovell.    A  Critical  Analysis  of  Out-Patient  Work 


412  DISPENSARIES 

from  the  Point  of  View  of  Efficiency.     Journal  of  the  American  Medical 
Association,  July  8,  1916. 

Sanford,  Dr.  Henry  L.  An  Efficiency  Test  of  Dispensary  Treatment 
of  One  Hundred  Cases  of  Gonorrhea.  Cleveland  Medical  Journal,  12 
(1913):  p.  813. 

Public  Health  Dispensaries  and  Health  Centers 

Association  of  Tuberculosis  Clinics,  New  York.  Annual  Reports, 
especially  the  6th  Annual  Report  (1913).  ''Dispensary  Control  of 
Tuberculosis." 

Crowell,  F.  EHzabeth.  The  Tuberculosis  Dispensary:  Method  and 
Procedure.  Published  by  the  National  Association  for  the  Study  and 
Prevention  of  Tuberculosis,  N.  Y.,  1916. 

Davis,  Michael  M.,  Jr.  The  Health  Center  Idea.  Public  Health 
Nurse  Quarterly,  January,  1916. 

Efficient  Dispensary  Clinics^  a  Requisite  for  Adequately  Coping 
with  Venereal  Disease.  Journal  of  the  American  Medical  Associa- 
tion, December  4,  1915. 

Evening  Clinics  for  Syphilis  and  Gonorrhea.  Social  Hygiene, 
June,  1915. 

What  the  Campaign  against  Venereal  Disease  Demands  of  Hospi- 
tals and  Dispensaries.  American  Journal  of  PubUc  Health, 
September,  1915. 

How  Efficient  Dispensary  Clinics  can  Help  Solve  the  Medical  Social 

Problems  of  Venereal  Disease.     National  Conference  of  Charitiea 

and  Correction,  1912,  p.  272. 

Eckstein,   Dr.   W.   G,     The  Genito-Urinary  Clinic:  Its  Relation  to 

Sanitary  and  Moral  Prophylaxis.     The  Postgraduate,  September,  1907. 

Guhck,  Dr.  Luther  S.  and  Ayres,  Leonard  W.     Medical  Inspection  of 

Schools.     Russell  Sage  Foundation,  N.  Y.,  1910. 

The  Modern  Hospital,  August,  1916.     (Industrial  Medicine)  and  sec- 
tions devoted  to  "Industrial  Department"  in  various  succeeding  issues. 
Local   Government   Board    (Great   Britain),     Regulations   regarding 
Venereal  Disease.     July  12,  1916.     (T.  Fisher  Unwin.) 

National  Committee  for  Mental  Hygiene.  50  Union  Sq.,  N.  Y.  Re- 
ports and  Publications,  and  Mental  Hygiene  (Quarterly). 

Piatt,  PhiHp  S.  The  Efficiency  of  Venereal  Clinics:  Suggested  Reme- 
dies for  Present  Defects.  American  Journal  of  Public  Health,  6  (  1916): 
p.  953. 

Smith,  Dr.  C.  Morton.     The  Relation  of  the  Physician  and  Social 


BIBLIOGRAPHY  413 

Worker  in  the  Effort  to  Save  Damaged  Ooode.  National  Conference  of 
Charities  and  Corrections,  1912,  p.  369. 

Stokes,  Dr.  John  H.  Hospital  Problems  of  Gonorrhea  and  Syphilis. 
Journal  of  the  American  Medical  Association,  December  23,  1916. 

Symposium  on  the  Hospital  and  Dispensary  Treatment  of  Venereal 
Disease  (N.  Y.  Academy  of  Medicine).  N.  Y.  Medical  Journal,  May 
17,  1913. 

'^ Social  Hygiene"  (Quarterly),  1915  et  seq. 

Thomson,  Dr.  Alec  N.  Attacking  the  Venereal  Peril.  (Pamphlet.) 
Read  before  Medical  Society  of  the  County  of  Kings,  N.  Y.,  February 

14,  1916. 

United  States  Children's  Bureau.     PubKcations  Nos.  3,  4,  6,  9,  11, 

15,  16,  19,  20.  (Infant  Welfare  Clinics,  Prenatal  Care,  Maternal 
Mortality.) 

Pay  Clinics 

Davis,  Michael  M.,  Jr.  Pay  Clinics  for  Persons  of  Moderate  Means. 
National  Conference  of  Charities  and  Corrections,  1915,  p.  228. 

Pay    Clinics  for    Tuberculosis.     Transactions    of    the    Twelfth 

Annual  Meeting  of  the  National  Association  for  the  Study  and 

Prevention  of  Tuberculosis,  1914. 

Hartshorn,  Dr.  Edward  and  Davis,  Michael  M.,  Jr.     A  Self-Suppori- 

ing  Eye  Clinic  for  Working  People.     Archives  of  Opthalmologj'',   43 

(1914):  No.  6. 

Howell,  Dr.  Thomas  and  Buckley,  Katherine.  Hospitals  and  Work- 
men's Compensation.  (Compensation  CHnics.)  The  Modern  Hospital, 
9  (1917):  p.  234. 

Public  Problems 
Vide  Numbered  References  22-24,  38-40. 

Committee  on  Social  Insurance,  Council  on  Health  and  PubHc  In- 
struction, American  Medical  Association.  Statistics  regarding  the  Medi- 
cal Profession.     Social  Insurance  Series,  Pamphlet  No.  7. 

Davis,  Michael  M.,  Jr.  The  Medical  Organization  of  Health  Insur- 
ance.    The  Medical  Record,  January  8,  1916. 

Organization  of  Medical  Service.     American  Labor  Legislation 
Review,  March,  1916,  p.  16. 
Emmons,  Dr.  Arthur  B.,  2d.     The  Profession  of  Medicine:  A  Col- 
lection of  Letters  from  Graduates  of  the  Harvard  Medical  School.     Harv- 
ard University  Press,  1915. 


414  DISPENSARIES 

Frankel,  Lee  K.  and  Dublin,  Louis  I,  Sickness  Surveys  (Metropolitan 
Life  Insurance  Co.)  as  follows: 

(Rochester)     U.  S.  Public  Health  Reports,  February  25,  1916, 
p.  434. 

(North  Carolina)     Ibid.,  October  13,  1916,  p.  2840. 
(Boston)     A  Sickness  Survey  of  Boston,  1916  (Pamphlet). 
Hay  hurst,  Dr.  E.  R.     Compulsory  State  Health  Insurance  and  Its 
Relation  to  Medical  Service.     The  Modern  Hospital  (1915),  6:  p.  420. 

Lambert,  Dr.  Alexander.     Medical  Organization  under  Health  Insur- 
ance.    (Reprint  by  Author  of  Address  at  Annual  Meeting  of  American 
Association  for  Labor  Legislation,  Columbus,  Ohio,  December  28,  1916.) 
Lyons,  E.  P.     The  Social  Status  of  Medical  Practice.     Journal  of  the 
American  Medical  Association,  December  19,  1914  (63:  271). 

Rubinow,  Dr.  I.  M.  Health  Insurance  in  Relation  to  the  Public  Dis- 
pensary. Council  on  Health  and  Public  Instruction,  American  Medi- 
cal Association.     Social  Insurance  Series,  Pamphlet  No.  3. 

Health  Insurance  in  Relation  to  Public  Health.     Ibid.     Pam- 
phlet No.  4. 
Schneider,  Franz.     A  Survey  of  the  Activities  of  Municipal  Health 
Departments  in  the  United  States.     Russell  Sage  Foundation,  1916. 

Smith,  Dr.  Winford  H.  Presidential  Address.  American  Hospital 
Association.     Proceedings  of  the  Association,  1916,  p.  19. 

Warbasse,  Dr.  James  P.  The  Sodalizaiion  of  Medicine.  Journal  of 
the  American  Medical  Association,  July  18,  1916,  63:  264. 

What  is  the  Matter  vyith  the  Medical  Profession?     Long  Island 
Medical  Journal,  July,  1912. 
Are  There  Too  Many  Doctors?     Ibid,  April,  1912. 


BY-LAWS  AND  RULES  416 


SUGGESTIONS  FOR 
BY-LAWS   AND   ADMINISTRATIVE   RULES   OF    A 

DISPENSARY* 

Article  I.     Governing  Board 

Section  L     The  management  of  this   Dispensary  shall 

be  vested  in  a  Board  of  Trustees,  of members  (nine 

to  fifteen).  The  Board  shall  be  chosen  at  the  Annual 
Meeting  of  the  Corporation,  and  its  members  are  to  serve 
for  three  years  each,  the  terms  to  be  so  adjusted  that  one- 
third  shall  expire  each  year. 

Section  2.  At  the  Annual  Meeting,  all  contributors  to 
the  funds  of  the  Dispensary,  as  well  as  all  members  of  the 
Corporation,  are  entitled  to  a  vote,  in  person  or  by  proxy. 

Section  3.  At  each  Annual  Meeting  shall  be  elected 
a  nominating  committee  of  seven,  to  present  nomina- 
tions at  the  next  Annual  Meeting  to  fill  vacancies  in  the 
Board  of  Trustees  and  in  the  officers  of  the  Dispensary  as 
hereinafter  provided.  Nominations  shall  also  be  received 
from  the  floor.     Election  shall  be  by  ballot. 

Section  4.  The  officers  of  the  Board  shall  include  a 
President,  a  Vice-President,  a  Treasurer  and  a  Secretary, 
elected  at  the  Annual  Meeting  and  serving  for  one  year,  or 
until  their  successors  are  appointed. 

Section  5.     The  duties  of  the  officers  shall  be  such  as 


*For  an  out-patient  department  of  a  hospital,  the  by-laws  on  pages 
425-426  may  be  substituted  for  portions  of  Articles  I-V  of  these  By- 
laws for  a  Dispensary, 


416  DISPENSARIES 

usually  appertain  to  their  respective  offices  (or  may  be 
specially  defined  according  to  local  conditions). 

Section  6.     Meetings  of  the  Board  of  Trustees  shall  be 

held  monthly  on ,  except  during  the  month  of  August. 

Special  meetings  may  be  called  by  the  President  or  the 
Secretary,  and  shall  be  called  at  the  request  of  any  three 
members. 

Section  7.    members  of  the  Board  shall  constitute 

a  quorum. 

Section  8.  The  Board  of  Trustees  shall  have  power  to 
fill  vacancies  arising  during  the  year  in  its  offices  or  mem- 
bership. 

Section  9.  The  Board  of  Trustees  shall  have  full  power 
to  conduct  all  affairs  of  the  Dispensary,  to  appoint  its 
medical  staff,  officers  and  employees,  and  to  establish  all 
needful  committees,  by-laws,  rules  and  regulations  for  the 
management  of  the  Dispensary,  and  to  alter  the  same  at 
its  discretion. 

Section  10.  All  appointees  to  any  position  in  the  Dis- 
pensary shall  hold  office  at  the  pleasure  of  the  Board. 

Section  11.     These  By-laws  of  the  Dispensary  may  be 

amended  by  a  vote  of  not  less  than members  of  the 

Board,  at  any  meeting,  provided  that  a  statement  of  their 
substance  has  been  sent  to  all  members  of  the  Board,  at 
least  one  week  in  advance  of  such  meeting. 

Article  II.     Executive  Committee 

Section  1.  There  shall  be  an  Executive  Committee  of 
the  Board  of  Trustees,  of  five  members,  chosen  by  the 
Board  to  serve  for  one  year,  or  until  their  successors  are 
appointed. 

Section  2.  The  Executive  Committee  shall  meet  on  the 
day  of  each  month,  and  at  such  other  times  as  it 


BY-LAWS  AND  RULES  417 

shall  determine.  The  Executive  Committee  shall  have 
the  powers  of  the  Board  of  Trustees  in  the  interim  of  Board 
meetings,  except  as  hereinafter  provided,  and  shall  have  the 
full  powers  of  the  Board  in  cases  of  emergency,  arising  from 
fire,  accident  or  other  calamity.  The  Executive  Committee 
shall  have  power  to  transfer  funds  appropriated  to  one 
department,  or  account  of  the  Dispensary,  to  another  de- 
partment or  account;  but  may  not  vote  new  appropria- 
tions except  in  emergency,  or  for  a  period  not  longer  than 
the  end  of  the  month  during  which  the  next  Board  of 
Trustees  meeting  is  held. 

Section  3.  The  Executive  Committee  shall  keep  accu- 
rate minutes  of  its  meetings  and  transactions,  and  shall 
make  a  report  to  the  Board  at  each  stated  meeting  thereof. 

Section  4.  No  payment  of  money,  except  for  salaries 
or  other  items  authorized  in  a  budget  approved  by  the 
Board,  shall  be  made  except  on  the  written  order  of  the 
Executive  Committee,  or  of  an  agent  thereof,  duly  author- 
ized by  the  Committee  to  take  action  in  the  matter. 

Section  5.  The  Executive  Committee  shall  have  power 
to  form  sub-committees,  which  may  include  members  of 
the  Board,  as  well  as  its  own  membership. 

Article  III.     Medical  Staff 

Section  1.  The  medical  work  of  the  Dispensary  shall 
be  carried  on  by  a  body  of  physicians  who  shall  be  appointed 
as  hereinafter  provided,  and  who  shall  be  di\dded  into 
such  Departments,  representing  the  various  branches  of 
medicine,  as  may  be  authorized  by  the  Board. 

Section  2.  The  following  grades  of  appointment  are 
recognized : — 

1.  Consulting  Physicians  or  Consulting  Surgeons. 

2.  Physicians  or  Surgeons. 


418  DISPENSARIES 

3.  Assistant  Physicians  or  Assistant  Surgeons. 

4.  Assistants  to  the  Physicians  or  Assistants  to  the 

Surgeons. 

5.  Resident  Physicians  (or  House  Officers). 

6.  Unofficial  Assistants. 

Section  3.  Appointments  to  grades  (1)  and  (2)  shall  be 
made  by  the  Board  of  Trustees  on  the  nomination  of  the 
Executive  Committee;  grades  (3),  (4)  and  (5)  by  the 
Executive  Committee,  on  the  nomination  of  the  Chief  or 
Chiefs  of  the  Department  concerned.  Preceding  action 
by  the  Trustees  or  the  Executive  Committee,  nominations 
shall  be  submitted  to  the  Medical  Advisory  Board. 

Section  4.  Such  items  concerning  a  nominee  shall  be 
submitted  as  may  be  required  by  the  Board  or  the  Execu- 
tive Committee.  No  nominations  for  appointment  upon 
the  Staff  shall  be  considered,  unless  the  nominee  has 
served  as  Resident  House  Officer  in  an  acceptable  hospital; 
except  in  cases  of  appointment  to  the  grade  of  Assistant  to 
the  Physicians  or  Assistant  to  the  Surgeons  when  an  excep- 
tion is  recommended  by  special  vote  of  the  Medical  Advi- 
sory Board. 

Section  5.  All  appointments  to  the  Staff  shall  be  for  a 
period  ending  on  December  31st  of  the  calendar  year  in 
which  they  are  made,  except  appointments  as  Unofficial 
Assistants  or  appointments  made  by  special  vote  of  the 
Board  of  Trustees  for  a  period  less  than  one  year. 

Section  6.  There  shall  be  a  Medical  Advisory  Board, 
consisting  of  five  physicians,  who  shall  not  be  members  of 
the  active  Staff  of  the  Dispensary,  and  shall  be  appointed 
by  the  Board  of  Trustees  at  the  Annual  Meeting,  to  serve 
for  one  year  or  until  their  successors  are  appointed.  It 
shall  be  the  duty  of  the  Medical  Advisory  Board  to  assist 


BY-LAWS  AND  RULES  419 

the  Board  of  Trustees  by  advice  and  counsel  as  to  questions 
of  policy  and  appointments. 

Section  7.  There  shall  be  a  meeting  annually,  at  a  time 
fixed  by  the  Trustees,  of  the  Board  of  Trustees  (or  the 
Executive  Committee  thereof),  with  the  Medical  Advisory 
Board,  the  heads  of  all  the  Departments  in  the  Dispensary, 
and  the  Superintendent. 

Section  8.  The  Staff  of  each  Department  shall  annually 
arrange  the  period  and  order  of  service  of  its  members, 
subject  to  such  rules  as  may  be  prescribed  by  the  Board  of 
Trustees.  Services  in  each  department  must  be  so  arranged 
that  there  shall  always  be  on  duty  at  least  one  member  of 
the  Staff  holding  the  rank  of  Physician  or  Surgeon. 

Section  9.  Unofficial  Assistants  include  those  who, 
without  holding  official  appointment,  assist  a  member  of 
the  official  Staff  in  any  department  of  the  Dispensary. 
No  physician  not  a  member  of  the  Official  Staff  is  allowed 
to  work  in  the  Dispensary  without  receiving  an  appoint- 
ment as  Unofficial  Assistant.  Such  appointments  are 
made  by  the  Superintendent  on  the  nomination  of  the 
Physician  or  Surgeon  who  is  in  charge  of  the  department 
for  the  service  during  which  the  assistant  is  to  work.  The 
form  of  appointment  for  Unofficial  Assistants  shall  state 
the  condition  and  the  length  of  service,  to  which  the  ap- 
pointee must  be  understood  to  agree. 

Section  10.  No  Unofficial  Assistant  shall  hold  such  an 
appointment  for  more  than  one  year. 

Section  11.  No  examination,  treatment  or  operation 
shall  be  undertaken  by  an  Unofficial  Assistant,  except 
under  the  direction  of  an  official  appointee  who  shall  be 
responsible  for  the  work  of  the  Unofficial  Assistant. 

Section  12.  No  clinic  shall  be  conducted  except  when 
an  official  member  of  the  Staff  of  the  department  is  in 
personal  attendance. 


420  DISPENSARIES 

Article  IV.     Superintendent  and  Administrative 

Staff 

Section  1.  The  chief  administrative  officer  of  the  Dis- 
pensary shall  be  the  Superintendent,  who  shall  be  appointed 
by  the  Board. 

Section  2.  The  Superintendent  shall  be  responsible  to 
the  Board  of  Trustees  for  the  proper  and  efficient  adminis- 
tration of  the  Dispensary  in  all  its  branches,  and  he  shall 
have  control  of  all  subordinate  officers  and  employees  and 
charge  of  the  building  and  appurtenances.  He  shall  be 
responsible  for  seeing  that  proper  records,  accounts,  and 
statistics  are  kept  of  the  medical  and  social  work  of  the 
Dispensary,  and  of  its  financial  transactions,  other  than  as 
recorded  by  the  Treasurer;  for  the  proper  recording  of  the 
attendance  of  the  members  of  the  Medical  Staff,  and  for 
the  purchase  and  care  of  supplies. 

Section  3.  As  the  stated  meeting  of  the  Board  in  Jan- 
uary, the  Superintendent  shall  present  to  the  Board  an 
annual  report,  reviewing  the  work  of  the  Dispensary  during 
the  preceding  fiscal  year,  and  he  shall  present  such  recom- 
mendations as  he  deems  desirable.  He  shall  also  present 
an  annual  Budget  of  expenses  which,  previous  to  considera- 
tion by  the  Board,  shall  have  been  passed  upon  by  the 
Executive  Committee;  and  when  necessary  at  other  times 
he  shall  present  supplementary  or  revised  Budgets,  the 
consideration  of  which  shall  follow  the  same  procedure. 

Section  4.  No  annual  Budget  shall  be  voted  upon  by 
the  Board  unless  a  copy  shall  have  been  in  the  hands  of 
the  members  at  least  one  week  before  the  meeting  at  which 
action  is  expected. 

Section  5.  All  subordinate  administrative  officers  and 
assistants  in  the  service  of  the  Dispensary  shall  be  appointed 
on  the  nomination  of  the  Superintendent. 


BY-LAWS  AND   RULES  421 

Section  6.  Subject  to  such  rules  or  policies  as  may  be 
prescribed  by  the  Board,  the  Superintendent  shall  have 
power  to  define  administrative  regulations  for  the  admission, 
registration,  transfer  of  patients;  for  the  administration  of 
the  medical  and  social  records;  for  the  collection  of  fees  from 
patients  and  for  the  remission  of  the  same ;  for  the  care  and 
accounting  for  all  monies  taken  in  at  the  Dispensary;  and 
for  such  other  administrative  matters  necessary  for  the 
proper  conduct  of  the  work. 

Section  7.  Except  by  special  permission  of  the  Super- 
intendent, the  purchase  of  supphes  must  be  made  by  an 
administrative  official  designated  by  him. 

Section  8.  The  signature  of  the  Treasurer  shall  be 
required  on  all  checks  paying  out  any  funds  of  the  Dis- 
pensary. On  all  checks  in  payment  for  salaries  or  for  sup- 
plies of  any  kind,  the  written  approval  or  signature  of  the 
Superintendent  shall  be  required. 

Article  V.     The  Joint  Council 

Section  1.  There  shall  be  a  Joint  Council  of  nine  mem- 
bers, including  three  members  of  the  Board,  three  of  the 
Medical  Staff,  and  three  of  the  executive  officials,  including 
the  Superintendent.  (In  small  institutions,  only  seven, 
with  only  one  executive  official,  the  Superintendent.) 

Section  2.  The  Trustees  shall  designate  annually,  as 
members  of  the  Joint  Council,  three  of  their  own  members, 
including  the  Chairman  of  the  Executive  Committee;  and 
three  of  the  executive  officials,  including  the  Superintendent. 
The  Heads  of  all  the  clinical  and  laboratory  departments  of 
the  Dispensary,  in  convocation,  shall  nominate  the  three 
staff  members  of  the  Joint  Council. 

Section  3.  The  Joint  Council  shall  meet  six  times  a  year 
at  dates  which  it  shall  fix.     The  Chairman  of  the  Executive 


422  DISPENSARIES 

Committee  shall  be  Chairman,   and  the  Superintendent 
shall  be  Secretary. 

Section  4.  The  Council  shall  have  power  to  receive 
suggestions,  recommendations,  or  statements  of  facts  or 
of  problems  from  any  person  or  department  within  the 
Dispensary,  and  may  make  recommendations  on  any  mat- 
ter referred  to  it,  or  of  its  own  motion.  Such  recommenda- 
tions may  be  made  to  the  Board  of  Trustees,  the  Medical 
Staff,  or  to  the  administrative  officers. 

Akticle  VI.    Administrative  Rules 

Section  1.  The  Executive  Committee  shall  fix  the  hours 
during  which  the  various  clinics  and  the  Pharmacy  are  to 
be  open;  the  hours  during  which  the  attendance  of  physi- 
cians is  required;  and  the  fees  to  be  charged  for  admission, 
treatment,  medicines,  operations,  or  other  services.  But 
any  fee  may  be  remitted  in  whole  or  part  by  the  Superin- 
tendent, or  with  his  authority,  in  order  that  no  patient 
shall  be  denied  a  needed  service  because  of  inability  to  pay 
for  it. 

Section  2.  All  members  of  the  official  staff,  and  also 
unofficial  assistants,  shall  register  daily  the  time  of  their 
arrival  and  departure  in  a  registration  book  provided  for 
that  purpose. 

Section  3.  The  Trustees,  after  consultation  with  the 
Medical  Advisory  Board,  shall  determine  the  diseases  or 
groups  of  diseases  which  are  to  be  treated  in  the  several 
cUnical  departments.  The  physician  or  surgeon  in  charge 
of  each  department  is  responsible  for  transferring  to  the 
proper  department  any  patient  who,  from  the  nature  of  his 
disease,  appears  to  have  been  improperly  assigned. 

Section  4.  In  case  a  physician  or  a  surgeon  in  charge  of 
a  department,  or  of  any  service,  is  unable  to  be  present  at 


BY-LAWS   AND  RULES  423 

a  clinic,  he  shall  promptly  notify  the  Superintendent,  who 
shall  assign  a  substitute.  An  assistant  is  to  notify  his 
chief  in  case  of  absence,  or  if  his  chief  cannot  be  reached, 
the  Superintendent. 

Section  5.  Full  and  careful  medical  records  shall  be 
kept  of  the  treatment  of  all  patients,  and  also  records  of  the 
patients  assisted  by  the  Social  Service  Department. 

Section  6.  The  medical  records  are  the  property  of  the 
Dispensary.  The  information  contained  on  any  record  is 
regarded  as  privileged  and  shall  be  divulged  only  as  re- 
quired by  law,  or  when  in  the  opinion  of  the  Superintendent 
the  furnishing  of  such  information  would  be  for  the  bene- 
fit of  the  patient  or  the  community. 

Section  7.  The  purpose  of  the  Dispensary  is  to  place  the 
best  medical  treatment  within  the  reach  of  persons  who 
would  otherwise  be  unable  to  procure  it.  It  is  not  the 
policy  of  the  Dispensary  to  treat  patients  who  are  able  to 
pay  the  usual  private  rates  for  the  medical  care  which  they 
require. 

Section  8.  It  is  the  responsibihty  of  the  Admission 
Desk  of  the  Dispensary,  under  the  Superintendent,  to 
ascertain  the  circumstances  of  each  new  patient,  and  after 
consideration  of  the  patient's  income,  family  responsibili- 
ties, and  the  probable  cost  of  the  medical  treatment  which 
he  would  require,  to  decide  whether  or  not  he  should  be 
admitted  to  the  Dispensary. 

Section  9.  Patients  who  in  the  clinics  appear  to  a  physi- 
cian to  be  able  to  pay  for  the  medical  care  which  they  re- 
ceive are  to  be  referred  back  to  the  Admission  Desk,  or  to 
the  office  of  the  Superintendent.  An  investigation  is  to 
be  made  of  every  such  case  and  if  it  is  believed  that  the 
patient  can  pay  a  private  physician,  the  patient  is  not  to 
be  treated  in  the  chnic,  except  in  cases  of  emergency. 

28 


424  DISPENSARIES 

Section  10.  All  patients  who  are  refused  treatment 
because  of  ability  to  pay  private  fees  are  to  be  referred  to 
the  office  of  a  physician.  If  the  patient  himself  has  not  a 
physician  in  mind,  he  will  be  given  the  name  and  address 
of  a  member  of  the  Staff  of  the  Dispensary.  The  selection 
of  the  member  of  the  Staff,  or  of  the  members,  to  be  given 
a  patient,  is  to  be  made  in  the  case  of  each  Department  after 
consultation  between  the  Superintendent  or  his  representa- 
tive, and  the  Chief  or  Chiefs  of  the  Department. 

Section  11.  All  compensation  to  members  of  the  medical, 
or  of  the  administrative  staff,  shall  be  paid  directly  by  the 
Dispensary,  and  no  member  of  the  medical  or  of  the  admin- 
istrative staff  shall  solicit  private  practice  from  Dispensary 
patients,  nor  receive  any  fee  or  reward  from  any  patient 
for  treatment  given  in  the  Dispensary. 

Section  12.  Supplies  shall  be  furnished  to  clinics,  or  to 
departments  or  to  individuals  within  the  Dispensary,  only 
for  Dispensary  purposes,  and  only  upon  written  requisition. 

Section  13.  Records  shall  be  made  of  all  supphes  or 
equipment  purchased  or  donated  and  a  current  hst  shall  be 
kept  of  all  articles  lost  or  missing. 

Section  14.  A  written  report  shall  be  made  of  any  acci- 
dent incidental  to  the  treatment  of  a  patient  in  the  Dis- 
pensary, and  forwarded  promptly  to  the  Superintendent. 

Section  15.  Physicians  are  to  give  practical,  plain 
directions  for  the  use  of  medicines,  and  the  pharmacist 
must  see  that  written  directions  accompany  the  prescrip- 
tions, when  dispensed.  The  term  "as  directed"  must  not 
be  used.  Except  in  unusual  circumstances,  not  more  than 
one  week's  supply  of  medicine  is  to  be  ordered  in  one  pre- 
scription. 

Section  16.  Students  may  be  admitted  to  any  depart- 
ment to  receive  instruction,  from  any  medical  school  the 


BY-LAWS  AND  RULES  425 

standing  of  which  is  satisfactory  to  the  Board  of  Trustees, 
and  with  which  arrangements  are  made  satisfactory  to  the 
Staff  of  the  department  concerned  and  to  the  Board. 

Section  17.  Medical  students  shall  not  undertake  any 
examination  or  treatment  of  patients,  except  under  the 
direction  of  their  instructor,  and  he  shall  be  responsible  for 
their  conduct  while  in  the  Dispensary. 


BY-LAWS  FOR  THE  OUT-PATIENT  DEPARTMENT 

OF  A  HOSPITAL 

(Assuming   general   Hospital   By-laws   providing   for   the 
usual  Board  of  Trustees,  Executive  Committee,  etc.) 

Article  — .     Out-Patient  Department 

Section  1.  There  shall  be  an  Out-Patient  Committee 
to  consist  of  three  members  of  the  Board  of  Trustees;  two 
members  of  the  House  Staff  (or  of  the  medical  board  of  the 
hospital) ;  three  members  chosen  by  the  Out-Patient  Council; 
and  the  Superintendent  of  the  Hospital. 

Section  2.  The  Out-Patient  Committee,  subject  to 
rules  established  by  the  Board  of  Trustees,  or  the  Executive 
Committee  of  the  Hospital,  shall  have  general  charge  of 
the  administration  of  the  Out-Patient  Department,  within 
the  appropriations  made  therefor  by  the  Board. 

Section  3.  Out-Patient  Council.  The  Heads  of  the 
Clinics  of  the  Out-Patient  Department,  including  the 
Laboratory,  shall  constitute  the  Out-Patient  Council. 
There  shall  be  quarterly  meetings  of  the  Council.  The 
Superintendent  of  the  Hospital  and  the  Supervisor  of  the 
Out-Patient  Department  shall  meet  with  the  Council  except 
during  sessions  for  the  election  of  officers,  or  other  executive 
business. 


426  DISPENSARIES 

Section  4.  There  shall  be  a  Supervisor  of  the  Out-Patient 
Department,  appointed  by  the  Board  of  Trustees,  on  the 
nomination  of  the  Superintendent  of  the  Hospital.  He  shall 
have  the  rank  of  an  Assistant  Superintendent  of  the  Hospi- 
tal, and  shall  hold  office  during  good  behavior,  or  at  the 
pleasure  of  the  Board  of  Trustees. 

Section  5.  The  Supervisor  of  the  Out-Patient  Depart- 
ment shall  have  administrative  charge  of  the  Out-Patient 
Department,  and  all  persons  who  are  engaged  in  any  way  in 
the  Out-Patient  Department  shall  be  responsible  to  him  so 
far  as  concerns  their  duties  therein.  All  directions  con- 
cerning work  in  the  Out-Patient  Department  shall  be 
issued  through  the  Supervisor  thereof. 


THE   MASSACHUSETTS  DISPENSARY  LAW 
(Chapter  131,  General  Acts  of  1918) 

An  Act  to  require  that  dispensaries  shall  be  licensed  by  the  state 
department  of  health. 

Be  it  enacted,  etc.,  as  follows: 

Section  1.  For  the  purposes  of  this  act  a  dispensary  is  defined  to  be 
any  place  or  establishment,  not  conducted  for  profit,  where  medical 
or  surgical  advice  or  treatment,  medicine  or  medical  apparatus,  is  fur- 
nished to  persons  non-resident  therein;  or  any  place  or  establishment, 
whether  conducted  for  charitable  purposes  or  for  profit,  advertised, 
announced,  conducted  or  maintained  under  the  name  "dispensary"  or 
"clinic,"  or  other  designation  of  like  import. 

Section  2.  It  shall  be  unlawful  for  any  person,  firm,  association  or 
corporation,  other  than  the  regularly  constituted  authorities  of  the 
United  States,  or  of  the  commonwealth,  to  establish,  conduct,  manage 
or  maintain  any  dispensary,  as  above  defined,  within  the  commonwealth, 
without  first  obtaining  a  license  as  hereinafter  provided. 

Section  3.  Any  person,  firm,  association  or  corporation,  desiring  to 
conduct  a  dispensary  shall  apply  in  writing  for  a  license  to  the  state  de- 
partment of  health.  The  application  shall  be  in  a  form  prescribed  by 
the  said  department,  and  shall  be  uniform  for  all  schools  of  medicine. 
There  shall  be  attached  to  the  application  a  statement,  verified  by  the 
oath  of  the  applicant,  containing  such  information  as  may  be  required 
by  the  said  department.  If,  in  the  judgment  of  the  said  department, 
the  statement  filed  and  other  evidence  submitted  in  relation  to  the  ap- 
plication indicate  that  the  operation  of  the  proposed  dispensary  will  be 
for  the  pubUc  benefit,  a  license,  in  such  form  as  the  said  department 
shall  prescribe,  shall  be  issued  to  the  appHcant.  Licenses  shall  expire 
at  the  end  of  the  calendar  year  in  which  they  are  issued,  but  may  be 
renewed  annually  on  appHcation  as  above  provided  for  their  initial  issue. 
No  license  shall  be  transferable  except  with  the  approval  of  the  said  de- 
partment. For  the  issue  or  renewal  of  each  Hcense  a  fee  of  five  dollars 
shall  be  charged,  except  to  incorporated  charitable  organizations  which 
conduct  dispensaries  without  charge  and  which  report  as  required  by 
law  to  the  state  board  of  charity.  The  fees  shall  be  paid  into  the  treas- 
ury of  the  commonwealth. 

Section  4.  The  public  health  council  of  the  said  department  shall 
make  rules  and  regulations,  and  may  revise  or  change  the  same,  in  ac- 
cordance with  which  dispensaries  shall  be  hcensed  and  conducted,  but 
no  such  rule  or  regulation  shall  specify  any  particular  school  of  medicine 
in  accordance  with  which  a  dispensary  shall  be  conducted. 

Section  5.  The  commissioner  of  health,  and  his  authorized  agent, 
shall  have  authority  to  visit  and  inspect  any  dispensary  at  any  time  in 


428  DISPENSARIES 

order  to  ascertain  whether  it  is  licensed  and  conducted  in  compHance 
with  this  act  and  with  the  rules  and  regulations  established  hereunder. 
After  thirty  days'  notice  to  a  licensed  dispensary  and  opportunity  to  be 
heard,  the  said  department  may,  if  in  its  judgment  the  public  interest 
so  demands,  revoke  the  license  of  any  dispensary. 

Section  6.  Dispensaries  legally  incorporated  or  in  operation  in  this 
commonwealth  at  the  date  of  the  passage  of  this  act,  shall,  on  applica- 
tion, be  permitted  to  continue  in  operation  for  the  remainder  of  the 
calendar  year  without  fee.  The  said  department  is  hereby  directed  to 
cause  an  inspection  to  be  made  of  all  such  dispensaries  prior  to  the 
thirty-first  day  of  December  in  the  current  year. 

Section  7.  Any  person,  firm,  association,  or  corporation  advertising, 
conducting,  managing,  or  maintaining  a  dispensary  as  defined  in  this 
act,  unless  the  same  is  duly  licensed  under  this  act,  and  any  person,  firm, 
association  or  corporation  wilfully  violating  any  rule  or  regulation  made 
and  published  under  the  authority  of  this  act,  shall  be  guilty  of  a  mis- 
demeanor, and,  on  conviction  thereof,  shall  be  punished  by  a  fine  of  not 
less  than  ten  dollars  nor  more  than  one  hundred  dollars.  A  separate 
and  distinct  offence  shall  be  deemed  to  have  been  committed  on  every 
day  during  which  the  violation  of  any  provision  of  this  act  continues 
after  due  notice  of  the  violation  is  given  in  writing  by  the  said  depart- 
ment to  the  authorities  of  the  dispensary  concerned.  It  shall  be  the 
duty  of  the  commissioner  of  health  to  report  to  the  attorney-general 
any  violation  of  this  act.     [Approved  April  2,  1918.] 


INDEX 


"Abuse,"  by  patients  able  to  pay, 
42-48,  55,  56 

Anti-tuberculosis  movement,  ef- 
fect on  growth  of  dispensaries, 
11,    12,     See  Tuberculosis. 

Admission  of  patients,  policy  of, 
60,  64,  67 

Admission  System,  in  Small  Out- 
Patient  Department,  292 

Admission  System,  forms  for  use 
in,  196-202;  functions  of,  193, 
194;  identifying  data  concern- 
ing patients,  201;  problems  of, 
192;  procedure  in,  194,  195, 
205;  re-admissions,  206;  staff  re- 
quired, 207,  208;  transfers,  206 

Admitting  officers,  203,  204 

Alphabetical  Index  to  Patients, 
197,  201 

American  College  of  Surgeons, 
403 

American  Hospital  Association, 
Committee  on  Dispensary  Work, 
ix,  23,  36,  38,  40,  55,  263 

Anaesthesia,  150,  170 

Annual  Reports,  frequent  defects 
in,  278,  279;  value  of  if  well 
prepared,  280,  281 

Apparatus,  Orthopedic,  provi- 
sion of,  172 

Apparatus  provided,  statistics  of, 
232 

Appointment  Cards,  for  patients, 
240,  241 

Appointments,  to  Medical  Staff, 
how  made,  88 

Associated  Out-Patient  Chnics  of 
New  York,  22 

"Baby      Chnics,"      see      Clinics, 

"Baby" 
Baltimore,  46,  309 
BibUography,  406-414 


Binet-Simon  Tests,  149 

Board  of  Trustees,  functions  of, 
81,  82,  88,  97,  100 

Boston,  4,  6,  7,  16,  39,  306,  309, 
354,  357 

Boston  Dispensary,  ix,  4,  6,  7, 
33,  48,  49,  50,  110,  242,  270, 
331,  336,  340,  341 

British  Royal  Commission  on 
Venereal  Diseases,  16,  313 

Brooklyn,   16 

Brooklyn  Hospital,  331 

Budgets,  family,  373;  margin  for 
care  of  health,  374 

Buffalo,  15,  16,  323 

Buildings,  cleaning  of,  131,  132; 
construction,  129;  floors  in, 
130;  general  planning,  121,  127, 
128;  ground  plans,  122-125, 
138,  140;  hghting  of,  129,  130; 
vestibule  or  covered  court 
needed,  127,  136;  toilet  facili- 
ties in,  132;  use  of  elevator  in, 
132;  walls,  painting  of,  130, 
131;  ventilation  of,  133 

Buildings,  for  small  Dispensary, 
136-139 

Buildings,  for  Out-Patient  De- 
partments, relation  to  hospital, 
121,  125,  126 

Burden  of  Sickness,  too  heavy  un- 
less distributed,  374;  how  to  be 
distributed,  375,  376,  380,  381 

Burweli,  Dr.  Thomas,  starting 
first  London  Dispensary,  2 

By-law^s  of  Dispensary,  sugges- 
tions for,  415-425 

By-laws  of  Out-Patient  Depart- 
ment, suggestions  for,  425,  426 

Cabot,  Dr.  Richard  C,  cited,  18; 
organized  first  Social  Service 
Department,  101 


429 


430 


INDEX 


California,  53 

Cannon,  Miss  Ida  M.,  book  on 
Social  Service,  102,  217 

Cardiac  Clinics,  see  Clinics,  car- 
diac 

Centralized  Medical  Control,  154, 
361 

Charity,  two  meanings  of  term, 
371;  people  not  wishing  to  ac- 
cept, 329;  "service"  versus 
"charity,"   371 

Chicago,  15,  46 

Chief  of  Chnic,  duties  of,  91,  92 

Children's  Medical  Clinic,  see 
Clinic,  Pediatric 

Cincinnati,  323 

Cleaning  of  Buildings,  131,  132 

Clerical  service  in  Dispensaries, 
76,  94 

Cleveland,  15,  16,  320,  322 

Clinics,  "Baby,"  equipment,  301; 
localization  of,  301;  manage- 
ment of,  302;  dispensing  milk, 
300,  303 

Clinics,  cardiac,  145 

Clinic,  Children's  Medical,  see 
Clinic,  Pediatric 

Clinics,  cost  of  various,  273 

Chnic,  Dental,  equipment  of,  178; 
"dental  hygienists"  in,  178; 
public  health  motive  in,  14 

Clmic,  Dermatological,  179 

"Chnic,"  defined,  27 

CUnics,  equipment  of,  see  under 
names  of  clinics 

Clinic,  Eye,  equipment  of,  174; 
refraction  work  in,  173;  pro- 
vision of  eye-glasses  in,  174; 
management  of,  175;  relation 
to  optician,  175 

Clinics,    gastro-enterology,    145 

Chnic,  Genito-Urinary,  168-171; 
scope  of,  168;  management  of, 
168-170;  equipment  of,  170 

Clinic,  Gynaecological;  relation  to 
obstetrics,  166;  management 
of,  167;  equipment  for,  167, 
168 

Clinic  hours,  often  inconvenient 
for  working  people,  329 


Clinic,  Industrial,  defined,  310; 
types  of  work,  311;  equipment, 
312;  problems,  312,  313,  367, 
368 

Clinic  Management,  77-79,  93 

Clinic,  Medical,  arrangement  of 
rooms,  133-135,  147;  a  clearing 
house  for  patients,  141;  equip- 
ment of,  142;  management  of, 
142,   143 

Clinic,  Medical,  number  of  pa- 
tients in,  143 ;  staff  required  for, 
144 

Chnic,  Neurological,  equipment 
of,  148,  149;  relation  to  psy- 
chiatry, 149 

Clinic,  Nose,  Throat  and  Ear, 
equipment  of,  176,  177;  ton- 
sillectomy in,  176;  nursing  serv- 
ice in,  177;  management  of, 
176,  177 

Chnics,  number  of  different  ones 
desu-able,  83-85 

Clinics,  "Nutrition,"  145 

Clinic,  occupational  diseases,  145 

Clinic,  Orthopedic,  management 
of,  172;  equipment  of,  171,  172; 
relation  to  Massage  and  Zan- 
der, 172 

Chnic,  Orthopedic,  provision  of 
apparatus,  172 

Clinics,  Pay,  see  Pay  Clinics 

Chnic,  Pediatric,  contagious  dis- 
eases in,  146;  management  of, 
146,  147;  staff  required  for,  147 

Chnics,  peripatetic,  in  small 
towns  and  in  country,  385,  396 

Clinic,  Prenatal,  equipment  of,  305; 
localization,  306;  relation  to 
maternity  hospital,  306;  to 
medical  education,  306;  to  ob- 
stetrics, 304 

Chnics,  Prenatal,  purpose  and 
method,  304;  development,  303, 
304 

Clinics,  Psychiatric,  relation  to 
Mental  Hygiene  movement,  308; 
development  of  systems  of 
clinics,  309;  relations  to  court, 
prisons  and  schools,  309,  310 


INDEX 


431 


Clinics,  School  Children's,  equip- 
ment, 308;  relation  to  medical 
school  inspection,  14,  307 

Clinic,  Surgical,  arrangement  of 
rooms,  135;  equipment  of,  151, 
152;  management  of,  151,  152; 
nursing  in,  152;  relation  to  Or- 
thopedics, Genito-Urinary  work. 
Gynaecology  and  Proctology, 
151;  treatment  of  fractures 
in,  anaesthesia  in,  150 

Clinic  treating  Syphilis,  equip- 
ment of,  181;  organization  of, 
180,  182;  relation  to  other 
cUnics,  148,  173,  180;  Wasser- 
mann  tests  in,  181 

Clinics,  tuberculosis,  145,  183; 
place  of,  in  general  Dispen- 
sary, 183 

CHnics,  Venereal,  part  of  pub- 
he  health  program,  313;  effect 
of  War  upon,  313;  efficiency  of, 
314,  315;  pay  chnics,  315 

Commercial  Dispensaries,  22,  368 

Community  Organization  of  Dis- 
pensaries, 391 

Consultations,  between  chnics,  214 

Contagious  Diseases,  146 

Contagious  Disease,  exclusion  of, 
204 

Co-operative  medical  practice, 
nature  of,  352 ;  pooling  of  equip- 
ment in,  352;  must  reach  more 
doctors,  356 

Corrective  Gymnastics,  87 

Cost  accounting,  267,  270,  271, 
272 

Cost  of  Dispensarj^  work,  small 
Out-Patient  Department,  294 

Cost  of  maintaining  Dispensaries, 
264^269 

Cost  of  Medical  Service,  63,  338 

Cost  per  visit  per  patient,  264- 
268,  variations  in,  264,  267 

Cost  Unit  for  Dispensary  Work, 
263 

Cystoscopy,  168,  170,  348 

Day,  Mrs.  Ehzabeth  Richards, 
cited,  105 


Dayton,  Ohio,  323 

Dental  Clinic,  see  Clinic,  Dental 

Dental  Clinics,  need  of,  as  sub- 
stitute for  "Dental  Parlors," 
177 

"Dental  Hygienists,"  178 

"Department"  of  a  Dispensary, 
defined,  28 

Department  of  Hygiene,  in  a  Dis- 
pensary, 163-165 

Dermatological  Chnic,  see  Chnic, 
Dermatological 

Diagnosis  Index,  230,  231 

Diagnostic  Clinic,  at  Mass.  Gen- 
eral Hospital,  332,  333 

Dietitian,  place  of,  in  Dispen- 
saries, 145 

Dignity  and  Comfort  for  Patients, 
362 

Dispensary,  a  center  of  organized 
medical  practice,  350 

Dispensaries,  admitting  patients 
to,  60,  64,  67.  See  Admission 
system 

Dispensary,  definition  of,  26,  27, 
34 

Dispensary,  efficient,  requirements 
of,  364,  365 

Dispensary,  "general"  and  "spe- 
cial," defined,  32 

Dispensary  patients,  economic 
classes  from  which  drawn,  52, 
53,  354 

Dispensary,  purpose  of,  71 

Dispensaries,  administrative  or- 
ganization of,  92-95 

Dispensaries,  advantages  of, 
reach  but  few  doctors,  357 

Dispensaries,  and  pauperism,  42, 
44 

Dispensaries,  broadening  scope  of 
358 

Dispensaries,  chief  present  de- 
ficiencies in,  360 

Dispensaries,  classification  of,  35 

Dispensaries,  cost  of  maintain- 
ing, 263-267;  cost  per  visit, 
264-268^ 

Dispensaries,  districting,  see  Dis- 
trict Dispensary 


432 


INDEX 


Dispensaries,  elements  in,  which 
attract  medical  staffs,  355 

Dispensaries,  "eligibility"  for 
treatment  in,  50,  53 

Dispensaries,  factors  in  organiza- 
tion of,  74,  80 

Dispensaries,  four  motives  in,  59 

Dispensaries,  function  in  medical 
education,  155,  158,  169 

Dispensaries,  future,  365 

Dispensaries,  general  principles 
of  organization,  82,  83,  99,  100 

Dispensaries,  location  of,  in  a  city, 
139,  140;  location  of,  in  U.  S., 
38,39 

Dispensaries,  modes  of  improving, 
by  pay  cUnics,  387;  by  relations 
with  industry,  388;  by  rela- 
tions wdth  insurance  groups,  388 

Dispensaries,  modes  of  improving, 
by  financial  aid,  389;  by  de- 
velopment of  pubhc  health 
cHnics,    390 

Dispensaries,  medical  scope  of, 
28-31;  medical  staff  of,  75 

Dispensaries,  number  of  patients 
in  U.  S.,  39,  40 

Dispensaries,  number  of,  in  U.  S., 
10,  36,  37 

Dispensaries,  Preventive  Medi- 
cine in,  162-165 

Dispensaries,  providing  special- 
ists for  people  of  small  means, 
353 

Dispensaries,  raising  funds  for, 
273,  277,  278,  281 

Dispensaries,  reimbursed  for  care 
of  public  dependents,  389 

Dispensary   "Abuse,"   42-48,   55, 

'    56 

Dispensary,  relation  to  hospital, 
366,  367,  403 

Dispensaries,  relation  to  medical 
practice,  345,  353 

Dispensaries,  social  groups  reached 
by,  354 

Dispensaries,  Special,  kinds  of, 
325;  limitations  of,  326;  rela^ 
tion  to  i)ublic  health  Dispen- 
saries, 327 


Dispensaries,  Volunteer  Workers 
in,  160-162 

"District  Dispensary,"  defined, 
35;  described,  366;  place  in 
community  plan,  392 

Districting  Dispensaries,  see  Dis- 
trict Dispensarj^ 

Drinking  Fountains,  132 

Ear  Clinic,  see  Clinic,  Nose, 
Throat  and  Ear 

Education,  comparison  with  med- 
ical service,  375,  383 

Efl&ciency  Conundrums,  261,  281 

Efficiency  Idea  in  Dispensaries, 
18,  19,  20,  21 

Efficiency,  in  Dispensaries,  re- 
quirements of,  364 

Efliciency  tests,  20,  76;  examples 
of,  249,  251,  252;  forms  for 
tabulating,  255,  258;  modes  of 
making,  255-259 

Electro-Therapy,  87,   190 

Elevators,  see  Buildings 

Equipment,  medical,  increase  in 
amount  required,  348;  clinical, 
see  under  names  of  clinics 

Europe,  Dispensaries  on  Con- 
tinent of,  4,  footnote 

Evening  CHnics,  343,  363,  401 

Examining  Rooms,  135 

Eye  CUnic,  see  CUnic,  Eye 

Eye  Diseases,  facihties  for  treat- 
ment, 334;  need  of  Pay  CUnic 
illustrated  by,  335 

Eye-Glasses,  provision  of,  174, 
175 

Family  Budgets,  373 

Family  physician,  passing  of,  345 

Fees    from    patients,     policy    of 

charging,  65,  66,  70;  how  fixed, 

68,    69;    rates    in    vogue,    275, 

276;   how   collected,    198,    199; 

remission    of,    197,    202,    274; 

X-ray  work,  186 
Financing  better  medical  service, 

372 
Floors   in   Dispensary   Buildings, 

130 


INDEX 


433 


Follow-Up  System,  two  senses  of 
term,  234,  235;  need  of,  233- 
235;  effect  on  clinic  efficiency, 
246,  247 

Follow-Up  System,  75;  principles 
of,  236,  237;  procedure  of  op- 
eration, 239,  240;  place  in 
various  clinics,  144,  147,  170, 
175,  177,  179,  182,  184;  cost  of, 
244 

Follow-Up  System,  forms  for  use 
in,  237,  238,  241,  243;  use  of 
post-cards  and  letters  in,  242- 
245 

Follow-Up  System,  doctor's  part 
in,  239,  246;  social  worker's 
part,  245;  clerk's  duties  in,  242, 
245 

Food  problems  of  dispensary  pa- 
tients, 144 

Formulary,  for  prescriptions,  188 

Four  Motives  behind  Dispen- 
saries, 23 

Funds  for  medical  service,  uses  of, 
377 

Gastro-Enterology,     sometimes 

branch     of     General     Medical 

Clinic,  145 
General  practitioner,   relation   to 

specialists,  345 
Genito-Urinary  Clinic,  see  Clinic, 

Genito-Urinary 
Goldwater,  Dr.  S.  S.,  viii,  22,  320; 

cited,  19 
Gonorrhea,  efficiency  tests  of  treat- 
ment, 251;  treatment  of,   167, 

169,  170 
Gonorrhea,    relation    to    syphihs 

from  public  health  standpoint, 

182 
Ground   plans,    for   Dispensaries, 

see  Buildings 
Gynaecology,  151,  166 
Gynaecological  Clinic,  see  Clinic, 

Gynaecological 

Health  Center,  defined,  18,  318, 

324;  future  of,  366,  392 
Health  Center,  Buildings  for,  137 


Health  Centers,  in  Buffalo,  323; 
in  Cleveland,  320-322;  in  New 
York,  320,  323;  in  Philadel- 
phia, 323 

Health  Center,  and  Specialty 
Center,  328 

Health  Education,  methods  of, 
164 

Health  Insurance,  368,  376,  379, 
391,  404 

Health  Work  in  Industry,  types  of, 
310-312 

''History-taking,"  in  clinics,   157 

"History  corridor,"  uses  of.  134 

Holmes,  Dr.  Oliver  Wendell,  7, 
8 

"Home  Patient  Department,"  de- 
fined, 34 

Hospital,  a  center  of  organized 
medical  practice,  350 

Hospital,  relation  of  buildings  to 
Out-Patient  Department,  121, 
125,  126 

Hospital,  relation  to  Dispensary, 
282,  283,  366,  403 

Hospital  reference  forms,  220,  221 

Hours  of  CUnics,  should  be  con- 
venient for  working  people,  329, 
342 

Hydro-Therapy,  87,  191 

Hygiene,  Department  of,  in  a 
Dispensary,  163-65 

Income  of  Physicians,  paucity  of 
data  on,  372;  gross  and  net  in- 
come, 339,  340 

Immigrants,  medical  service  avail- 
able to,  346 

Industrial  Chnics,  310-313.  See 
Clinic,  Industrial 

Identifying  Data  concerning  pa- 
tients, 201 

"Index  Visible,"  of  use  in  follow- 
up  system,  239 

Industrial  Dispensary,  future  of, 
367,  391;  recent  growth  of,  16 

Industrial  Dispensaries,  developn 
ment  of,  391 

Industrial  Health  Work,  see 
Health  Work  in  Industry 


434 


INDEX 


Inquiries  concerning  patients,  dis- 
posal of,  194,  208 

Installments,  payment  of  fees  by, 
how  managed,  173,  276,  277 

Johns  Hopkins  Hospital,  10 

Laboratory,  87,  184,  185;  in  smaU 
hospital,    Out-Patient    Depart- 
ment, 287;  in  Medical  Clinic, 
142;   in   Pediatric   Clinic,    146; 
in  Surgical  CUnic,  151;  records 
for,  217,  220;  statistics  of,  232. 
See  Wassermann  tests 
Lakeside     Hospital     Dispensary, 
control  of  dispensary  "abuse," 
54,  55;  pay  clinic  at,  331 
Legal  regulation  of  Dispensaries, 
22,    330,    368;    in    New    York 
45,  369;  in  Massachusetts,  369, 
427 
Lighting,  see  Buildings 
"Line  and  Staff"  organization,  94 
Location  of  Dispensaries,  139,  140 
London,  first  Dispensary  in,  1 
London,   Dispensaries  in,  3 
Lumbar  puncture,  181 

Massachusetts  General  Hospital, 
10,  101,  213 

Massachusetts  law  licensing  Dis- 
pensaries, 427,  428 

Massage,  87,  172,  190 

Mayo  CUnic,  21,  330,  344,  368 

Medical  colleges,  394 

Medical  Education,  function  of 
Dispensary  in,  155,  158,  159, 
395;  recent  improvements  in, 
394 

Medical  Equipment,  increase  in 
quantity  and  expense,  348 

Medical  placement  of  patients, 
203 

Medical  practice,  individualistic, 
347;  specialist,  351;  co-opera- 
tive, 352;  Dispensary  and  hos- 
pital centers  of  co-operative 
practice,  350,  351 

Medical  profession,  relation  to 
Dispensaries,  345 


Medical  profession,  individualistic 
trend  of,  397;  development  of 
organized  practice  in,  350- 
353,  399 

Medical  profession,  need  of  bet- 
ter facilities  for,  384,  394;  pro- 
portion in  Dispensaries,  357 

Medical  Records,  see  Records, 
Medical 

Medical  School  inspection,  14,  307 

Medical  service,  insufiiciencies  of, 
383 

Medical  Staff,  grades  of  appoint- 
ment 88-90;  how  appointed, 
88;  length  of  services,  90,  91; 
relation  of  hospital  and  Dis- 
pensary staffs,  88,  99,  100 

Medical  Staff,  number  of  patients 
to  be  seen  by,  in  given  time,  143 

Medical  Staff,  organization  of,  96, 
97,  99,  100 

Medical  Staff,  salaries  for,  needed, 
60,  355;  effect  on  Dispensary 
costs,  269;  how  secure  money 
for,  381,  390 

Medical  Staff,  why  attracted  to 
Dispensaries,  355 

Medicines,  a  chief  feature  of  first 
Dispensaries,  2 

Medicines,  provision  of,  see 
Pharmacy 

Medical  Students,  144,  156;  his- 
tory-taking, 157;  examining  pa- 
tients, 157 

Mental  Hygiene,  and  Dispensaries 
14,  15,  149,  150 

"Milk  Stations,"  see  Baby  Chnics 

Modern  Hospital  (magazine)  cited, 
282,  283,  312 

Moore,  Miss  Anna,  Study  of  1000 
Dispensary  patients,  46-48 

Mt.  Sinai  Hospital,  N.  Y.,  19, 
40,  87 

Nationality  of  Patients,  record- 
ing of,  228 

Neurological  Clinic,  see  Clinic, 
Neurological 

New  York  City,  4,  7,  15,  20,  39, 
42,  43,  46,  60,  259,  266,  270, 


INDEX 


435 


302,  306,  308,  314,  320,  323, 
354,  357 

Nose,  Throat  and  Ear  Clinic,  see 
Clinic,  Nose,  Throat  and  Ear 

Nursing,  in  Dispensaries,  76 

Nurses,  pupil,  use  of  in  Dispen- 
saries, 159,  160 

Nurses,  training  of,  in  Dispen- 
saries, 159 

"Nutrition"  CHnics,  145 

Occupational  Disease  CHnics,  145 
Occupations  of   patients,   record- 
ing of,  227,  228 
One  Hundred  Per  Cent  Idea,  317 
Operations,  Statistics  of,  231 
Ophthalmological    Clinic,     see 

CHnic,  Eye 
Optician,  in  Eye  Chnic,  175 
Organization  in  medicine,  349 
Orthopedic    Clinic,      see    Clinic, 

Orthopedic 
Orthopedics,  growth  of,  171,  290, 

291;  effect  of  War  on,  171 
Osier,  Dr.  William,  quoted,  9 
"Out-Patient    Department,"    de- 
fined, 34 
Out-Patient      Departments,      or- 
ganization    of,     98-100 
"Out-Patient     Institution,"      de- 
fined, 34 
Overcrowding  in  Dispensaries,  19, 
269 

Pay  Clinics,  definition  of,  329, 
330,  relation  to  public,  334- 
339;  relation  to  doctors,  339- 
341;  relation  to  Dispensary, 
341-343 

Pay  Clinics,  co-operative  enter- 
prises of  physicians,  343,  344 

Pay  Clinics,  fees  in,  331;  com- 
pensation of  medical  staff  in, 
332;  equipment  and  manage- 
ment, 333 

Pay  Chnics,  growth  of,  331;  future 
of,  344,  387 

Pay  Clinics,  relation  to  free 
clinics,  333,  342,  343 

Patent  medicines,  329,  350 


Patients  and  physicians,  relations 
in  cHnics,  153-155 

Patients,  should  be  under  cen- 
trahzed  medical  control,  361 

Pediatric  CHnics,  145-147 

Periodical  Medical  Examinations, 
145,  164 

Peripatetic  CHnics,  385 

Pharmacy,  dispensing  medicines, 
rules  for,  188;  equipment  of, 
188;  fees  for  medicines,  189; 
use  of  formulary,  188 

Philadelphia,  4,  45,  49,  323 

Physical  Gymnastics,  190 

Physicians,  income  of,  gross  and 
net,  339,  340 

Physicians,  shortage  of,  in  poor 
districts,  383 

PoHcy  in  admitting  patients,  60- 
62,  64,  67 

Population,  proportion  of  doctors 
to,  382,  384 

Population  Unit  for  health  service, 
317 

Posters  and  Exhibits,  131,  164 

Post-graduate  teaching  in  Dis- 
pensaries, 158 

Pregnancy  CHnics,  see  Clinics, 
Prenatal 

Prenatal  Clinics,  see  CHnics,  Pre- 
natal 

Prenatal  Care,  its  value  in  saving 
Hfe,  306 

Prenatal  Work,  166 

Presbyterian  Hospital,  N.  Y.,  270, 
271,  272 

Preventive  Medicine  in  Dispen- 
saries, 162-165 

Preventive  Work,  must  be  local- 
ized, 140 

Proctology,  151 

Psychiatric  CHnics,  308-310.  See 
CHnics,  Psychiatric 

Psychiatry,  relation  to  Neurologi- 
cal CHnic,  149 

PubHc  Dependents,  reimburse- 
ment of  Dispensaries  for  care  of, 
389 

PubHc,  does  not  understand  trend 
of  modem  medicine,  353,  397, 


436 


INDEX 


404;  need  of  this  understand- 
ing, 405 

Public  health  Dispensaries,  12, 
13;  definition  of,  34;  militant 
purpose  of,  315;  localization  of, 
316;  visiting  nurse  in,  316 

Public  health  motive,  establishing 
Dispensaries,  17,  297 

Public  health  work,  militant  or- 
ganizations in,  11,  13 

Quacks,  30,  336,  337 

Raising  funds  for  Dispensary  work, 
273,  277,  278,  281,  401 

"Rand"  visible  iudex,  of  use  in 
foUow-up  system,  239 

Records,  administrative,  for  keep- 
ing track  of  expenses,  273 

Records,  four  kinds  of,  210 

Records,  Hospital  and  Dispen- 
sary, relation  between,  220,  222, 
223 

Records,  medical,  210-213;  book 
records  abandoned,  211;  card 
record  forms,  197,  200,  211; 
use  of  rubber  stamps,  212;  filing 
and  distribution,  213;  central 
record  room,  213,  214 

Record  Room,  central,  213,  214 

Records,  Social,  216,  217 

Records,  supervision  of  contents 
of,  223,  224 

Record  system,  with  central  rec- 
ord room,  213,  214;  without  cen- 
tral record  room,  215 

Recovery  Rooms,  150,  176,  178 

"Refers,"  214,  217 

Registrar,  importance  in  a  Dis- 
pensary, 223 

Relations  between  different  Dis- 
pensaries in  a  community,  98. 
See  District  Dispensary 

Rochester,  N.  Y.,  15 

St.  Louis,  49 

Salaries,  for  Medical  Staffs.     See 

Medical  Staff,  salaries  for 
Salvarsan,  injection  of,  182 
Savage,  Mr.  Charles  C.,  cited,  43 


School  children,  promotion  of 
health  among,  14 

School  Children's  Clinics,  307- 
308.  See  CHnics,  School  ChU- 
dren 

School  nurse,  177 

SeK-Diagnosis  and  Self-Treat- 
ment, 30,  329,  336,  337 

Sexes,  separation  of,  how  far 
needed  in  waiting  rooms,  142, 
145 

Shrady,  Dr.  George  F.,  cited,  42 

Sickness,  see  Burden  of  Sickness 

Simultaneous  operation  of  clinics, 
86,  87 

Small  Dispensaries,  33 

Small  Dispensary,  buildings  for, 
136-139 

Small  Dispensary,  organization  of, 
95,  96 

Small  Hospital,  Out-Patient  De- 
partment, admissions  and  fees, 
292;  records,  292;  nursing,  293; 
social  service,  293;  cost  of,  294; 
financing  of,  295;  correlation 
with  wards,  291 

SmaU  Hospital,  Out-Patient  De- 
partment, value  of,  282,  285; 
clinics  needed  in,  84-86,  288, 
290;  organization  of,  289,  296; 
Laboratory  and  X-ray  in,  287; 
rooms  and  equipment,  289; 
medical  staff  and  services, 
290 

Small  Hospital,  Out-Patient  De- 
partment for  private  cases,  284 

Social  diagnosis,  105 

Social  Groups  receiving  poor  medi- 
cal service,  338 

Social  needs  of  patients,  72 

Social  Service  Advisory  Com- 
mittee, functions  of,  107,  108 

Social  Service,  in  Dispensary,  76, 
98;  defined,  101;  kinds  of  cases 
dealt  with,  102,  104;  adminis- 
tration of,  in  Clinics,  147; 
functions  performed,  103;  mode 
of  selecting  cases,  109,  110; 
utihzes  community  resources, 
104,  106 


INDEX 


437 


Social  Service,  how  much  needed 
in  Dispensary,  117-119 

Social  Service,  in  Small  Hospital 
Out-Patient  Department,  293, 
294 

Social  Service,  needed  in  various 
clinics,  144,  145,  147,  149,  152, 
167,  172,  177,  182,  184 

Social  Service  Departments,  or- 
ganization of,  107,  113,  119, 
120;  records  of,  216,  217 

Social  Surveys  of  Dispensary  pa- 
tients, 113,  118,  120 

Social  Workers  and  nurses,  116 

Social  Workers,  assigned  to  Clinics, 

110,  111 

Social  Workers,  relation  to  phy- 
sicians, 108,  109,  113;  specializa- 
tion of.  Ill,  112 

Social  Workers,  specialization  of, 

111,  112 

Social  -Workers,  training  of,  114, 
115,  160 

Social  Unit  Organization,  323 

Special  Dispensaries,  see  Dispen- 
saries, special 

Specialist  Medical  practice,  351 

Specialists,  cost  of  treatment  by, 
328;  much  of  treatment  is  am- 
bulatory, 328;  increased  use  of, 
353 

Specialists,  lack  of,  outside  of 
cities,  385;  in  poorer  districts 
of  cities,  386 

Specialization  in  medicine,  rise  of, 
345,  347;  continued  develop- 
ment probable,  350;  organiza- 
tion of,  essential,  350 

Specialization,  in  pubUc  health 
services,  316,  317;  need  of  co- 
ordination of,  317 

Specialization,  within  a  clinic,  86; 
within  staff  of  Surgical  Clinic, 
151 

Specialities,  extent  to  which  Dis- 
pensary should  recognize,  84,  85 

Statistics,  in  Dispensaries,  210; 
ambiguities  in,  224;  data  de- 
sirable, 227,  228;  forms  for 
tabulation,  228,  229;  principles 


for  deciding  what  to  record, 
227,  230 

Statistics,  of  Attendance,  193, 
208;  of  apparatus  provided,  232; 
of  laboratory  work,  232;  of 
nationality,  228;  of  occupation, 
228;  of  operations  performed, 
231;of  X-ray  work,  232 

Stevens,  Edward  F,,  viii;  plans  of 
buHdings,  122-125,  138 

Superintendent  of  Dispensary  or 
Out-Patient  Department,  82,  94, 
95,  100 

Superintendent  of  Hospital,  re- 
lation to  Out-Patient  Depart- 
ment, 81,  98,  99 

Surgical  Clinic,  see  CUnic,  Surgical 

Syphilis,  treatment  of,  148,  168, 
179-183.  See  Clinic  treating 
Syphilis 

Taxation,  for  better  health  serv- 
ice, 379 

"Teaching  Dispensary,"  defined, 
35,  56,  57,  61 

Teaching  Dispensary,  rewards  to 
staff,  355;  future  development, 
370,  393 

Teaching,  medical,  its  value  in 
Dispensaries,  9;  a  motive  in  de- 
veloping Dispensaries,  7,  8,  10. 
See  Medical  Education 

Throat  Clinic,  see  CHnic,  Nose, 
Throat  and  Ear 

Time  and  Continuity,  requisites 
for  efficient  clinics,  153 

Time  required  for  patients,  143 

Thayer,  Dr.  W.  S.,  cited,  43,  46 

Thornton,  Miss  Janet,  studies  of 
cost  of  medical  service,  50-53 

Toilet  facilities,  see  Buildings 

Transfers,  215,  217,  218.  See 
Admission  System 

Treatment  Departments,  87,  88, 
187-191 

Trustees,  Board  of,  functions,  see 
Board  of  Trustees 

Tuberculosis  Chnics,  12,  183,  298- 
299;  a  miUtant  agent,  297.  See 
Clinic,  tuberculosis 


438 


INDEX 


Tuberculosis,  sometimes  branch  of 
General  Medical  Clinic,  145 

Unit  of  Dispensary  Work,  225 
Urine,    examination    of,    routine, 
141 

Valentine,  Mr.  Robert  G.,  cited, 
72,  73 

Veeder,  Dr.  Borden  S.,  cited,  49, 
50,  56,  57 

Venereal  disease  clinics,  15,  16, 
30,  31;  co-ordination  of,  183. 
^ee  Clinics,  Venereal;  Clinic 
treating  Sj^philis ;  Genito-Uri- 
nary  Clinic;  Gonorrhea;  Syph- 
ilis 

Venereal  Disease,  program  of  con- 
trol, 15 

Venereal  Diseases,  four  types  of 
treatment  facilities,  30,  336;  re- 
quire cUnics  for  adequate  treat- 
ment, 313;  a  special  province  of 
Dispensarj'^,  314 

Venereal  Diseases,  cost  of  treat- 
ment, 337 

Ventilation,  see  Buildings 

Vestibule,  see  Buildings 

Virchow,  Dr.  Rudolph,  71,  73 

Visiting  Nursing,  145,  153,  166, 
184,  305;  in  co-operation  with 
various  chnics,  299,  300,  305, 
308,  309,  311,  316;  a  common 
factor  in  PubHc  Health  Dis- 
pensaries, 316 


Visiting  Nursing,  co-ordination  of 
special  services  in,  323,  324; 
in  small  towns,  324 

Visits  per  patient,  a  useful  test  of 
work,  248;  variations  among 
clinics,  249 ;  cautions  in  employ- 
ing as  efficiency  test,  253,  254 

Volunteer  Workers,  uses  of,  160- 
162;  training  of,  161,  162 

Wages,  loss  of,  because  of  incon- 
venient clinic  hours,  329,  363 

Waiting  rooms,  separation  of 
sexes  in,  142,  145,  168,  289 

War,  effect  upon  Medical  science 
and  practice,  v,  vii,  viii,  399, 
401;  effect  on  Dispensary  staffs 
and  on  costs,  400;  developing 
orthopedics,  171,  290,  291; 
developing  venereal  clinics,  313 

Wassermann  tests,  181,  314 

Wilhams,  Dr.  J.  Whitridge,  cited, 
306 

Wright,  Henry  C,  eflSciency  test 
by,  257 

X-ray  Department,  87,  151,  186, 
187;  record  forms  for,  217,  219; 
statistics  of,  232;  in  small  Hos- 
pital Out-Patient  Department, 
287,  288 

X-ray  Department,  work  for  pri- 
vate patients,  187,  288 

Zander,  87,  172,  190 


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29 


Reclaiming  the  Maimed 

A  Handbook  of  Physical  Therapy 


By 

R.  TAIT  McKENZIE,  M.  D. 

Major,  Royal  Army  Medical  Corps, 

Professor  of  Physical  Therapy, 

University  of  Pennsylvania. 

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The  remarkable  work  accomplished  by  Major  McKenzie  and  as- 
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thousands  of  men  who  were  previously  considered  as  permanently  dis- 
abled, as  well  as  his  success  in  restoring  and  returning  to  civil  pursuits 
thousands  of  others,  is  fully  described  in  this  important  book.  Not 
only  does  Major  McKenzie  explain  what  has  been  done,  but  he  offers 
many  new  methods,  together  with  brand  new  apparatus,  while  the  text 
is  supplemented  by  an  unusual  collection  of  photographs  and  drawings 
which  make  his  material  instantly  applicable  for  use  by  the  medical 
man,  the  masseur  or  nurse. 

Major  McKenzie's  methods  of  treatment  are  now  actually  being 
taught  and  practically  applied  in  the  hospitals  of  the  Military  Hospitals 
Commission  of  Canada  along  the  lines  described,  while  the  Surgeon 
General's  office  of  the  United  States  Army  has  approved  of  and  urged 
the  immediate  publication  of  the  book.  It  is,  therefore,  particularly 
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A  Handbook  of  Antiseptics 

By 
HENRY  DRYSDALE  DAKIN,  D.Sc.,  F.I.C,  F.R.S. 

AND 

EDWARD  KELLOGG  DUNHAM,  M.D. 

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The  object  of  this  handbook  is  to  present  a  concise  account  of  the  chief 
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during  the  present  war.  The  unparalleled  severity  and  frequency  of 
wound  infection  found  there  has  led  to  considerable  advances  in  our 
knowledge  of  these  antiseptics,  and  of  methods  for  their  successful  em- 
ployment as  found  in  Dr.  Dakin's  recent  broad  experience  on  the  various 
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The  current  European  practice  is  here,  for  the  first  time,  collected  into 
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Zinsser.     Infection  and  Resistance 

An  exposition  of  the  Biological  Phenomena  underlying 
the  Occurrence  of  Infection  and  the  Recovery  of  the  Animal 
Body  from  Infectious  disease. 

By 

HANS  ZINSSER,  M.D. 

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Columbia  University,  New  York;  Major,  Medical 

Officers'  Reserve  Corps,  U.  S.  A. 

With  a  Chapter  on  Colloids  and  Colloidal  Reactions. 

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Department  of  Chemistry,  Stanford  University. 
Second  edition  completely  revised,  $4.25 

Since  the  publication  of  the  first  edition  of  this  book,  four  years  ago, 
it  has  been  accepted  as  the  standard  work  on  the  subject  in  our  language 
and  has  been  termed  the  "classic  on  Immunity  in  all  languages," 

The  book  has  been  rewritten  and  entirely  reset  and  all  important 
changes  necessitated  by  the  lapse  of  time  have  been  made,  also  much 
new  material  has  been  added. 

The  chapters  on  Anaphylaxis  have  been  almost  completely  rewritten. 
The  Abderhalden  reaction  having  been  proved  to  be  an  interesting 
camouflage,  the  material  in  that  section  has  been  revised  and  the  more 
recent  work  on  Enzymes  added.  The  development  of  conceptions  of 
non-specific  serum  and  cellular  reactions  has  been  discussed,  while  a 
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Typhoid  Fever :  Considered  as  a 
Problem  of  Scientific   Medicine 

By 
FREDERICK  P.  GAY 

Professor  of  Pathology,  University  of  California. 

8vo.    $2.50 

Professor  Gay  treats  the  development  and  present  status  of  our 
knowledge  concerning  this  important  malady  as  viewed  from  the  stand- 
point of  its  mechanism.  While  not  designed  to  restrict  its  field  to  either 
the  clinic  or  laboratory,  it  serves  to  point  out  the  relations  of  one  to  the 
other,  to  indicate  the  dependence  of  practice  on  theory,  and  the  ap- 
plicability to  human  need  of  investigation  that  formerly  may  have 
seemed  to  aim  merely  at  the  gratification  of  intellectual  curiosity. 
Professor  Gay  has  aimed  to  strike  a  balance  between  purely  clinical  and 
laboratory  treatment,  together  with  the  public  health  aspects  of  the 
disease,  following  the  life  history  of  the  typhoid  bacillus  in  order  to  gain 
insight  into  the  problem  as  a  whole.  The  work  is  not  encyclopedic, 
although  the  references  to  original  sources  are  sufficiently  ample  to  lead 
the  prospective  investigator  to  full  sources  of  information.  This  book 
is  without  doubt  the  best  balanced  and  most  comprehensive  work  yet 
published  on  this  highly  important  disease. 


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